Overview
Step Therapy is a program designed especially for people
who take prescription drugs regularly to treat ongoing
medical conditions, such as arthritis and high blood pressure. The program is a new approach to getting patients the prescription drugs they need, with safety, cost and — most importantly — their health in mind. The program makes prescription drugs more affordable for most members and helps our organization control the rising cost of medications. It allows patients and their families to receive the affordable treatment they need and helps our organization continue to provide prescription- drug coverage.
In Step Therapy, drugs are grouped in categories, based on cost:
• Front-line drugs — the first step — are generic drugs proven safe, effective and affordable. These drugs should be tried first because they can provide the same health benefit as more expensive drugs, at a lower cost.
• Back-up drugs — Step 2 and Step 3 drugs — are brand-name drugs such as those you see advertised on TV. There are lower-cost brand drugs (Step 2) and higher-cost brand drugs (Step 3). Back-up drugs always cost more.
2. Who decides which drugs are covered in Step Therapy?
Step Therapy is developed under the guidance and direction of independent doctors, pharmacists and other medical experts. Together with Express Scripts, this professional panel reviews the most current research on thousands of drugs that have been clinically tested and approved by the FDA for safety and effectiveness. Then they recommend appropriate prescription drugs for a Step Therapy program, and our organization’s pharmacy benefit plan chooses the drugs that will be covered. You may give the patient a copy of the list of drugs covered under the Step Therapy program.
What Happens at the Pharmacy
3. Why couldn’t I fill my prescription at the pharmacy?
The first time a patient submits a prescription that isn’t for a front-line drug, the pharmacist should inform the patient that our plan uses Step Therapy. This simply means that if the patient would rather not pay full price for the prescription drug, they must first try a front-line drug.
To receive a front-line drug:
• The patient should ask the pharmacist to call the
prescribing doctor and request a new prescription.
OR
• The patient should contact the prescribing doctor to get a new prescription.
Only a doctor can change a patient’s current prescription to a front-line drug covered by our program.
4. How do I know which front-line drug my doctor
should prescribe?
The choice of drug should be the doctor’s decision. You can give the patient a list of front-line prescription drugs covered by our plan. The patient should give this list to his or her doctor. Knowing which drugs are covered will allow the doctor to prescribe an appropriate drug.
5. What can I do when I need a prescription filled immediately?
If the patient has just started taking a prescription drug regularly or is a new member of our plan, he or she may be informed at the pharmacy that the prescribed drug isn’t covered. If this should happen and the patient needs the medication right away, the patient can:
• Talk with the pharmacist about filling a small supply of the prescription right away. (The patient may have to pay full price for this quantity of the drug.) Then, to ensure the medication will be covered by our plan, the patient should ask the prescribing doctor to write a new prescription for a front-line drug. Only a doctor can approve a first-step drug and write a new prescription.
To Receive a Back-up Drug
6. What can I do if I’ve already tried the front-line
drugs on the list?
With Step Therapy, more-expensive brand-name drugs are usually covered as a back-up in the program if:
1) The patient has already tried the generic drugs covered in our Step Therapy program
2) The patient can’t take a generic drug (for example, because of an allergy)
3) The patient’s doctor decides, for medical reasons, that a brand-name drug is needed If one of these situations applies, the patient’s doctor can request an override so the patient can take a back-up prescription drug. Once the override is approved, the patient pays the appropriate copayment for this drug. If the override is not approved, the patient may have to pay full price for the drug.
7. What happens if my doctor’s request for an override is denied?
Our pharmacy-benefit plan’s guidelines exclude certain drugs from coverage. To learn more about which drugs are excluded from our plan, members should consult their benefit information. To receive a copy of the criteria our plan uses to decide which overrides will be covered, members should call Patient Services at Express Scripts.
OR
• Our plan has an appeals process. If a patient wants to file an appeal to have a prescription drug covered, please write to the Fund Administrator.
8. What can I do if my appeal is denied?
Patients can talk again with their doctors about prescribing one of the safe, effective, first-step drugs covered by our plan’s Step Therapy program. Copayments will usually be most affordable for one of these drugs. Or, patients can choose to pay full price for a drug not covered by our pharmacy-benefit plan.
More About Generic Drugs
9. What are generic drugs?
Even though generics usually have a different name, color and/or shape, a generic alternative has the same chemical makeup and same effect in the body as the original brand-name drug. Generics, which have been around for a long time, have been rigorously tested, and the U.S. Food & Drug Administration (FDA) has approved them as safe and effective. Unlike manufacturers of brand-name drugs, the companies that make generic drugs don’t spend a lot of money on research and advertising. As a result, their generic drugs cost less than their original brand-name counterparts — and they can pass the savings on to patients.
