Step Therapy – Relevant for Consumerism?

One of the key programs we used at Express Scripts to manage trend was Step Therapy.  What this means is that a patient is required to use a less expensive drug (typically a generic) prior to using a more expensive drug.  A day-to-day example of this is with antibiotics.  Anyone with kids knows that you start your child on a generic antibiotic and if that doesn’t work you escalate to a stronger (and more expensive) product.

Step Therapy has two challenges.  One, consumers got “rejected” at the Point-of-Sale (POS) (i.e., the pharmacy) and were upset they couldn’t get the drug their doctor prescribed.  Two, how do you handle programs like this (that are effective) with CDHC where the consumer is responsible for managing their own money and edits are typically frowned upon.

Patients generally don’t understand plan design and edits and don’t know what to do.  As you can see from the Express Scripts 2004 Drug Trend Report (pg. 121), a material amount of people filed no claim (great savings) but did take action (i.e., no negative clinical outcomes identified).  We developed a rapid response program to inform them what to do to get their drug covered which seemed to help.

But, what do you do in a consumer driven plan where you just have a high deductible.  I for one advocated that I would like edits that forced me to save money.  Perhaps, I needed an override code, but I wanted to know when and how to save money.  Left to my own devices and having to research every prescription would be a burden.

I think this still remains to play out, and I am sure there are lots of opinions here.