In this thread, Ann Hedonia states:
This is referred to as “step therapy,” and like many issues, it’s more complicated than this. For starters, drug pricing is arbitrary and set by what the market will bear. Why does one drug cost $30 a month and another drug cost $3000 a month, anyway? It usually has nothing to do with the actual cost to develop and produce the drug by the manufacturer, or how long it has been on the market, and everything to do with what the pharmaceutical companies can get away with charging for it.
But back to step therapy. Insurers are increasingly using it to control costs, while patient advocacy groups and the pharmaceutical industry are generally against it.
The Alliance for Patient Access (AfPA), which is a supposedly a patient advocacy group, but is criticized for its ties to the pharmaceutical industry states:
Exerpted from here. More info here, including this graphic.
I’ve now run into this several times in the last year or so, and I have a good health insurance plan through my employer. In one case, my insurer told me that my asthma medication that I’ve been using for a decade was being dropped from the formulary. I was forced to switch to a different medication, which failed to control my asthma symptoms, and then another. After two failures, which took many, many months and numerous doctor visits, I was able to get my doctor to write a request to have my original medication prescribed again. About a year after my original medication was dropped, I was finally back on my original medication…but my airway is still so inflamed that I haven’t seen much improvement yet. My exercise program has gone to shit due to the resumption of asthma symptoms, and I now feel a lot less healthy than I did a year ago. The worst part is that my preferred medication is actually cheaper than the other two drugs the insurance company insisted I try. The only reason I can tell that my medication was dropped was because the manufacturers of the other medications were able to work out a deal with my insurer.
In another case, I got a bad case of poison ivy. I went in to the urgent care clinic to get something stronger than OTC hydrocortisone and Caladryl, and walked out with a prescription for generic Westcort, which has been on the market for years. When I got to the pharmacy, they wouldn’t fill the prescription, because the urgent care doctor was somehow supposed to know that I was required to try two other preferred medications first. :rolleyes: So with the urgent care clinic closed for the weekend, I was forced to either pay for the medication myself, delay treatment, or go into an ER and be seen by another doctor. Again, I later found out that both of the preferred medications were comparable in cost to generic Westcort, so I don’t see what is being gained here other than a sneaky way for my insurer to avoid paying for my prescription.
The bottom line is that the so-called step therapy, while marketed as a way to control costs, often ends up either denying or delaying care to patients, or forces patients off of long-term drug therapy. Also, while the underlying premise is that similar drugs are basically interchangeable, this is rarely the case, because not all drugs work the same way in different people, and this includes efficacy as well as side effects.