Why Does the Price of Medication Change?

Blues Perspectives

| 4 min read

Man organizes his medications in his pill box
The rising cost of medications is a concern for everyone: patients, doctors, employers, insurance companies. As new drugs come into the market, they can be more expensive for patients. The more expensive the medication is, the more inaccessible it is for those in need. This is why Blue Cross Blue Shield of Michigan and Blue Care Network are continuously developing new ways and working with stakeholders and policy makers to help manage prescription costs to make treatments affordable and attainable for members. That’s where step therapy comes in. It’s a way to make sure you get the safest, most effective and most reasonably priced medication available to treat your condition.

What is step therapy?

Step therapy is a program that guides your prescription drug coverage. The program starts by covering less expensive drugs that have been proven effective for patients with similar conditions before you take a “step” to a different medication.

How does it work?

Your doctor prescribes you medicine and, typically, the prescription will be filled as written. But if the prescription is for a high-cost or new drug with lower cost alternatives available, or for a drug with dangerous side effects, Blue Cross may examine your medical and pharmacy history to ensure you’ve tried lower cost, established treatments first. If you haven’t, your treatment may start with those medications. If the suggested alternative drug does not relieve symptoms or help your condition, the more expensive drug will then be covered. This ensures that all approved, safe and cost-effective options have been tried before more expensive drugs are used, saving you money.

How will you know if your medicine requires step therapy?

Blue Cross’ pharmacy database will alert your pharmacist if the prescribed drug requires step therapy. Your pharmacist will contact your doctor and your doctor will reconsider the prescription path. Your doctor may choose to explore alternative options or prescribe a medication that does not require step therapy.

Is step therapy safe?

Absolutely. Just because a medicine is more expensive, doesn’t necessarily mean it is more effective. Providing high quality, safe medication is the top priority of our team of pharmacists and physicians that routinely develop and review step therapy guidelines to ensure there’s a minimum risk for side effects and complications. Here are some examples of how the pharmacy team reviews medication requests through the prior authorization process to keep patients safe:
  • One of our pharmacists noticed a member with leukemia had prior authorization requests on the same day from two different oncologists for two medications meant to be given separately, not together. The drugs, Bosulif and Sprycel, are secondary cancer-fighting drugs. Taking both would increase side effects, including nausea, vomiting, diarrhea, fatigue, lowered white blood cell counts and increased chance of infection. The medical office staffs agreed the member couldn’t take both medications. The change also saved the cost of the second drug, $13,000 per fill.
  • Our pharmacy services team received a prior authorization request from a hospital for the drug Onfi for a patient. The drug, used to treat a rare and severe seizure disorder, was prescribed to a young adult patient being discharged. The pharmacy request was for double the dose that the patient had been taking in the hospital. The error could have caused patient central nervous system depression, low blood pressure, sedation, trouble breathing and possibly coma or death.
  • There are two lengths of times for radiation therapy for breast cancer treatment. The American Society for Radiation Oncology (ASTRO) recommends that many patients can receive a shorter course of treatment with equal outcomes. The prior authorization process evaluates if a patient qualifies for a shorter length of treatment – which would save the patient significant time, shortening treatment and helping them resume their normal life sooner.

Want to learn more?

Read the updated guidelines for more information on step therapy and how it works at Blue Cross. And understand more about prescriptions and pharmaceuticals by checking out our online guide. More from MIBluesPerspectives:
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MI Blues Perspectives is sponsored by Blue Cross Blue Shield of Michigan, a nonprofit, independent licensee of the Blue Cross Blue Shield Association