Notice that this is a PBM (Express Scripts) is owned by the insurance company https://www.pharmacytimes.com/view/cigna-completes-purchase-of-express-scripts and has its own mail order pharmacy. Notice what was read from the letter from Express Scripts to the prescriber that they were MANDATING step therapy – step therapy is starting with the least expensive – or the PBM gets the largest kickback, rebate, discount from the pharma- for a particular med. From what I heard from the prescriber reading the letter, the prescriber should chose the LEAST EXPENSIVE MEDICATION in this particular class/category. The particular medication mentioned is typically used to treat ADD/ADHD, another subjective disease/mental health issue. No test to determine how well – or poorly – the cheapest med would work for the pt and/or how much better that the med prescribed would have worked better than the cheapest med. I have not had to deal with step therapy in years, but with subjective diseases, will/could the PBM decide any improvement in QOL issues – no matter how small… would/could decide that the particular least expensive med… is clinically significant enough to declare not necessary to try an more expensive meds.
It will be interesting how these PBM will deal with pts who have had pharmacogenomics testing done and this DNA test will clearly show which med the pt’s metabolism would be the best metabolized …which would indicate optimal improvement of QOL, at lower doses and less side effects and should save all involved out of pocket costs. https://www.nigms.nih.gov/education/fact-sheets/Pages/pharmacogenomics.aspx
Filed under: General Problems
I hope all PBM’s read your blog!