Sounds good so far. However, if your insurer believes there’s a better alternative to the medication your doctor prescribes, you are required to try that first. Only if that drug fails will the original prescription be filled. An insurer may insert several cheaper drugs and wait for them all to fail before finally agreeing to cover the drug your doctor originally prescribed. This process could take weeks. Or months. Meanwhile, what’s happening to your health?
There is little oversight of step therapy. Generally, insurers do not have to prove the effectiveness of their step therapy policies or even take into account the side effects of their substitute drugs. NPF is actively working on a solution to step therapy. To find out more, and how it affects your state, please click here.
STEP THERAPY IS SUPPOSED TO SAVE INSURERS MONEY.
In a study comparing spending on schizophrenia medications in Georgia’s Medicaid program, step therapy saved the state $19.62 per member per month. Cheaper drugs – savings all around. Right?
Wrong. The same study found that after the introduction of step therapy, the Medicaid program had to spend more money on outpatient services – $31.59 per member per month. That’s because less-effective medications often led to higher health costs later.