Step therapy for ARBs

[diana.papshev]

Anonymous member request:

"I am a clinical pharmacist responsible for drug and drug class reviews for formulary management. Would you be able to tell me how common it is for commercial plans to institute a step therapy for antihypertensives mandating the trial of an ACE Inhibitor prior to using an ARB."

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[Nochmar]

My opinion of this would be that it was much easier to step therapy an ARB when they were newer to the market and less well understood. However, at that time many ACE-I were also quite expensive.
I think this is one of the issues that is still best served by thorough educations of your provider base. There isn't much compelling evidence to justify ARB's over ACE-I's except the perception that everyone will get a cough from the ACE-I. A cost-effective comparison would speak volumes.

[diana.papshev]

Anonymous member feedback:

"we have had this in place for a long time, but i think the advent of generic arb's will probably change the process."

[chantell.reagan]

In an analysis of 10 national and regional health plans, approximately 4/10 plans have some step-therapy and/or prior authorization for at least one of the ARBs, requiring a trial of ACE inhibitors before approval.

As we reported late last year, Cozaar and Hyzaar are the first ARBs expected to be available as generics, beginning in April 2010. As a result, you may start to see the number of plans that utilize step therapy in this area.

Additional resources:
Aetna Angiotensin-receptor blocker policy (non-Medicare) – select ARBs subject to step therapy
BCBS Alabama policies – no step therapy for ARBs
BCBS Florida policies – no step therapy for ARBs
BCBS Michigan step therapy – no step therapy for ARBs
Cigna ARB policy – prior authorization
Coventry formulary search – no step therapy for ARBs
Excellus step therapy - no step therapy for ARBs
Highmark formulary search – select ARBs on formulary
Independence Blue Cross antihypertensives policy – step therapy for new starts
Regence policies – no step therapy for ARBs

[diana.papshev]

Anonymous member feedback:

"It is becoming more common place due to cost containment.
Unless there are patient issues with side effects, more plans have implemented the use of Step Therapy to control plan costs"

[GSOwens]

I work with a Medicare Plan and initially we had step therapy for ARBs based on clinical evidence. With a stable membership, I think that a step therapy program works very well, however if turnover is an issue, it will be hard to manage due to the lack of Rx history. In my case, I found that I was approving most requests that failed the ST edit and it became a laborious process with little to no ROI and based on the rebates I had to give up to use ST, it was not worth the effort. That said, with Cozaar going generic, I am reconsidering a Step within the ARB category.

[chantell.reagan]

We received this anonymous feedback from one of our members:

"Our plan instituted an ACE before ARB strategy at least 5 years ago. On the upside, we've limited ARB use, on the downside we've lost rebates because of contractual issues that do not allow for them when a step therapy is in place. Thus, every member that passes through the step costs us in full for the ARB. We are contemplating a double step therapy as a result which requires use of losartan or losartan/HCTZ before any other branded ARBs."