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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

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Last modified: August 30, 2021