Step-Therapy Program to Lower Rx Costs, Keep Members Happy

November/December 2010, Vol 3, No 6 - Conference Highlights AMCP

A year­long step­therapy program focusing on 10 therapeutic drug classes that also attempted to mini­mize member dissatisfaction with any changes among these drugs lowered the average gross cost per claim by nearly 13% while denying only 10.2% of prior author­ization (PA) requests.

The program was initiated by CVS/Caremark; the drugs it focused on included proton pump inhibitors (PPIs), nonsedating antihistamines (NSAs), selective serotonin reuptake inhibitors, 3­hydroxy­3­methyl ­glutaryl­coenzyme A reductase inhibitors, angiotensin­converting enzyme inhibitors/angiotensin receptor blockers, nasal steroids, hypnotics, bisphosphonates, urinary incontinence drugs, and cyclooxygenase­2 (COX­2) inhibitors.

As with other step­therapy programs, members are required to fill a prescription for a generic before select­ing single­source brands, but the program also allows a choice of 1 select preferred brand in most classes. Members and physicians were notified about the pro­gram 60 days and 30 days before implementation, and a dedicated call center was set up to handle PAs and other questions. The program effectiveness was meas­ured through average gross cost per claim and average generic­dispensing rate.

Following program implementation, gross cost per claim fell from $72.75 to $64.50 per average claim, and generic­dispensing rate rose from 57.5% in August 2009 to 72.8% by July 2010. Generic­dispensing rate improved significantly in all classes except for COX­2 inhibitors; the program had the greatest impact among the PPI and NSA classes, which saw average gross cost per claim drop by $41.14 and $15.25, respectively. The call center handled 7600 calls between August 2009 and March 2010; 16.7% of callers began the PA process but were converted to a preferred brand or generic; and 54.1% of PA requests were approved.

The analysis did not adjust savings for increases in wholesale price inflation or for the effects of new brand medications

Related Items
Can Technologic Innovations and Formulary Considerations Improve Healthcare Outcomes?
Charles Bankhead
June 2018 Vol 11, No 4 published on June 25, 2018 in Conference Highlights AMCP
AMCP Nexus 2017 Highlights
December 2017 Vol 10, No 9 published on January 3, 2018 in Conference Highlights AMCP
Challenges and Opportunities in Managing Type 2 Diabetes
Laura Morgan
June 2017 Vol 10, No 4 published on June 22, 2017 in Conference Highlights AMCP
Payers’ Perspective: Incorporating Real-World Evidence in Patient Care
Lilly Ostrovsky
April 2017 Vol 10, No 2 published on April 18, 2017 in Conference Correspondent, Conference Highlights AMCP
Implications of Real-World Data and Pharmacoeconomics for Managed Care
Lilly Ostrovsky
May 2016 Vol 9, No 3 published on May 25, 2016 in Conference Highlights AMCP
Last modified: December 23, 2010
  •  Association for Value-Based Cancer Care
  • Value-Based Cancer Care
  • Value-Based Care in Rheumatology
  • Oncology Practice Management
  • Rheumatology Practice Management
  • Urology Practice Management
  • Inside Patient Care: Pharmacy & Clinic
  • Lynx CME