Page 46 - 2017 V1 InsideOut

Step Therapy Basics:
What it is & how it works
Step therapy is applied widely in the commercial insurance market and government sponsored programs
to control costs and risk for payers. Drugs that treat a wide range of chronic conditions, including auto- immune disorders, hemophilia and cancers, frequently fall beneath step therapy programs.
Step therapy requires a patient to rst use a medicine that typically costs less, known as a Step 1 drug that typically appears beneath the Tier 1 bene t level. If the Step 1 drug is proven ineffective for the patient’s speci c illness or injury, the insur- ance plan will cover the more expen- sive drug, or Step 2 drug; the Step 2 drug typically appears in Tier 2 cost levels. If the Step 2 drug is proven ineffective for the patient’s speci c
illness or injury, the insurance plan will either approve other drugs in Step 2/Tier 2 categories, or provide coverage for a Step 3 drug (if avail- able). Throughout the process, pa- tients and their providers may appeal “step-therapy edits.”
Bene ts and Challenges
Proponents believe U.S. healthcare consumers bene t directly and in multiple ways from step therapy policies. In addition to saving money for prescription drugs, step therapy reduces employers’ costs for employer- sponsored healthcare bene ts, as well as costs for individuals who pur- chase healthcare coverage.4 Patients receive medications that are “tried and true” for the diagnosed disease, thus limiting potential adverse events.7 Due to other DUR components, pro- ponents say the extensive oversight
addresses potential abuse from pa- tients, pharmacists and prescribing physicians.4 Managed care experts also believe such policies keep drug pricing in check.8
Many patient advocacy groups, professional organizations and physi- cians consider the strict preautho- rization process of DUR intrusive to patient privacy, and further delays or prevents patient access to health- care.9 Patients have testi ed before state legislators how they experi- enced worsening conditions after having to “fail rst” on lower tiered medications.10 Other patients have said that although they maintain the same doctor, switching health insur- ance coverage from one carrier to another causes the process to start anew. Appeal’s processes, which require the patient and/or physician to complete complex forms, is an
DRUGS THAT TREAT A WIDE RANGE OF CHRONIC CONDITIONS, INCLUDING AUTOIMMUNE DISORDERS, HEMOPHILIA AND CANCERS, FREQUENTLY FALL BENEATH STEP THERAPY PROGRAMS.
42 | InsideOut