Public Employee Press

Q & A about Step Therapy

By GREGORY N. HEIRES

The DC 37 Health and Security Plan implemented a program Dec. 1 that requires participants to try cheaper and preferred medications for certain chronic conditions before they use more expensive drugs.

The step therapy program affects individuals who have new prescriptions for the covered drugs. Individuals who are already taking any of these medications are not affected by the change. Union and employer drug plans around the country are implementing step therapy programs as they try to cope with the rising expense of prescription medications. Drug costs have increased much faster than overall inflation in recent years. The change should help the plan save an estimated $3.5 million a year.

The changes do not apply to members and retirees covered by the benefit programs at city cultural institutions and the New York Public Library system. Under the program, doctors will be asked to request “step-one” medications the first time they prescribe drugs for patients in a covered treatment category. If the first treatment does not work well, the patient can be given a more costly “step-two” drug.

What is Step Therapy?
Step Therapy is a program for members taking prescription drugs to treat certain ongoing medical conditions with safety, cost and most importantly your health in mind.

It allows you and your family to receive the affordable treatment you need and helps the DC 37 Health and Security Plan contain the rising cost of prescription drug coverage.

• The program starts with generic drugs in the “first step.” The generics covered by the plan are proven to be effective in treating many medical conditions. You have the lowest co-payment for a first step generic drug.
• More expensive brand name drugs are usually covered in the second step. These require higher co-payments.

What medical conditions are covered?
Effective Dec. 1, 2004, the drug categories in the step therapy program included high blood pressure, dermatitis and eczema, attention deficit hyperactivity disorder, asthma and allergy, depression, rheumatoid arthritis, and diabetes.* Effective March 1, 2005, the step therapy program will add pain and arthritis medication as well as drugs for ulcer and gastro-esophageal reflux disease.

* The plan’s prescription drug benefit provides diabetes medication for Medicare-eligible retirees only.

Who decides what drugs are covered?
Step therapy was developed under the guidance and direction of independent, licensed doctors, pharmacists and other medical experts. With Express Scripts Inc., which administers the drug benefit for the union, they reviewed current research on thousands of drugs tested and approved by the FDA for safety and effectiveness. They then developed a list of recommended drugs for the program.

I am currently taking a Step Two medication, how will step therapy affect me?
If you are currently taking a Step Two medication prior to Dec. 1, 2004, you will not be affected. However, if you were prescribed a Step Two medication in the past and have not filled the prescription in at least the last four months, you will not be able to fill that medication without first trying a Step One drug.

What should I do when my doctor prescribes a medication for a Step Therapy condition for the first time?
Ask your doctor to prescribe a Step One medication. You can provide your doctor with a copy of the Step Therapy program’s medications, which was mailed with the benefit change notification letter and is printed below. Physicians may contact Express Scripts’ prior authorization department to request approval for a Step Two drug, if they feel a specific patient’s case is unique and warrants special handling. However, Express Scripts will not automatically approve such requests.

Do I need an approval when my doctor changes my prescription from a Step One drug to a Step Two drug?
If the initial treatment with a Step One drug is deemed to be ineffective, the patient may be prescribed a Step Two drug. You will not need approval to fill the new prescription at the pharmacy, since Express Scripts will have a record of the Step One prescription.

Why couldn’t I fill my prescription at the pharmacy?
If this is the first time you are being prescribed medication for a Step Therapy condition, and your doctor did not prescribe a Step One drug, your pharmacist will receive a message indicating that our plan has a Step Therapy program. The pharmacist will contact the physician to request a new prescription for a step one drug. If a physician is unavailable, the member/patient will be responsible for obtaining the new prescription.

If you choose to get your written prescription filled as is, you will pay the full cost of the medication, and the drug will not be covered by the plan.

Who should I call if I have questions or want a copy of the medications in the Plan’s Step Therapy program?
You may ask additional questions or request a copy of the medications in the Step Therapy program by calling Express Scripts at 1-800-467-2006.

The list of medications in the Step Therapy program will also be posted on the union’s Web site, www.dc37.net. Follow the links to the DC 37 Health and Security Plan to access detailed information about the plan’s prescription drug benefit.