Drug Protocol Management:

Drug Protocol
Management:
Step Therapy
� Why Step Therapy?
When many different drugs are
available for treating a medical
condition, it is sometimes useful to
follow a step-wise process for finding
the best treatment for individual
people. This step-wise process is
called “step therapy”.
The first step in a step therapy process
is usually a simple, inexpensive
treatment that is known to be safe and
effective for most people. This
treatment is known as “first line”
therapy, and it is the preferred therapy
for most people. If first-line therapy
does not work or causes problems for
a person, the next step is to try
second-line therapy.
Express Scripts offers a Step Therapy
program that will help ensure that you
are receiving the most appropriate drug
therapy while helping to reduce your
pharmacy costs.
In the long term, the Step Therapy
program can increase the amount of
money available to your plan sponsor
for covering prescriptions. This can
result in an increase in your overall
drug benefit.
� Step Therapy in Action
In partnership with both pharmacists
and physicians, Express Scripts has
developed an automated Step Therapy
program as a Drug Protocol
Management tool. This program is
geared to ensure that you are receiving
the best medication recommended for
your condition. Here’s how it works:
� When a prescription for a secondline
drug is being processed at your
pharmacy, the online computer
system will scan your recent
prescription records.
� If the system finds a record for a
first-line alternative, the Step
Therapy program will not interrupt
the dispensing process.
� If the system does not find a
prescription for a first-line
alternative to your prescription, it
will alert the pharmacist that your
prescription is not a covered
benefit. The system will indicate
why the prescription is not covered
and list covered first-line
alternatives.

� Frequently Asked Questions
Q. Why should use of second-line
drugs be limited?
A. Second-line drugs may have more
side effects, be more difficult to
take, and/or be more expensive
than their first-line alternatives.
Q. Can I get coverage for a secondline
drug even if I have not tried a
first-line drug?
A. In some cases, yes. Exception
processes are available for the rare
cases in which no first-line drug is
appropriate. If you meet certain
medical criteria, you may be able to
get coverage through your plan’s
usual prior authorization process.
Q. Does a change to a first-line drug
have to be approved by my doctor?
A. Yes, because it involves a change
in the drug being dispensed. No
prescriptions will be changed
automatically based on the Step
Therapy program.
Q. If my prescription is changed, will
my copay also change?
A. Your copay may be lower. In many
cases, the first-line drugs are
generic and therefore have a lower
copay than the second-line drugs,
which are typically brand-name
products. Copayments for first line
drugs are never higher than copays
for their second-line alternatives.
Q. What medications and conditions
are included in the Step Therapy
Program?
A. In general, Step Therapy programs
include drugs used for conditions
with many drug therapy choices.
Express Scripts has developed
Step Therapy protocols to improve
the use of medications for the
following conditions (the specific
drugs are listed in parentheses):
� Pain/arthritis (non-steroidal antiinflammatory
drugs)
� High blood pressure
(angiotensin II receptor
antagonists, ACE inhibitors)
� Depression (SSRI’s)
� Gastrointestinal disorders
(Proton Pump Inhibitors)
Q. How are the first- and second-line
drugs chosen?
A. Selection of the first- and secondline
drugs takes place after careful
review of medical literature,
manufacturer product information,
and consultation with medical
professionals. These steps are
taken to make sure that the
protocols reflect the most current
and appropriate drug therapy
recommendations.
© 2002 Express Scripts, Inc.
All Rights Reserved
Rev. 5-2004