Step Therapy Protocol: Defined

What is step therapy protocol? How does it work?

Step therapy protocol simply means that a member may need to use one type of medication before another. Anthem Prescription has edits, which are simply electronically transmitted instructions to the pharmacist, patient, or physician, on some drugs to control utilization, to ensure that appropriate prescribing guidelines are followed, and to help members access high quality, yet cost-effective prescription drugs. Step Therapy, Prior Authorization and Quantity Limitation are three of the ways these goals are achieved.

Why do drugs like Vioxx and Celebrex, for instance, have prescription drug coverage edits in place?

A group of trained clinicians at Anthem Prescription continuously reviews new drugs and research studies. If a particular drug has a high potential to be over prescribed, or taken for non-FDA approved uses, a drug edit may be needed. In the case of Vioxx and Celebrex, it was found that these drugs should be reserved for patients who are at high risk for gastro-intestinal (GI) track bleeding or distress. Therefore, it may be prudent for a member to try, for instance, a regular non-steroidal anti-inflammatory drug (NSAID) (i.e. ibuprofen), which should be an equally effective medication.

These medications require step therapy:

Aciphex Enbrel* Penlac*
Advair* Foradil* Prevacid
Arava* Humira* Prilosec
Bextra* Kineret* Serevent*
Celebrex* Nexium Vioxx*

If my physician decides that the edited medication is needed for my situation, what does my physician need to do?

Your physician will need to submit a letter or fax including the following details:
  • member name
  • member ID number
  • diagnosis
  • drug name
  • reasons for the appeal
  • physician name
  • physician address and physician
  • specialty

Requests may be addressed to:

Anthem Prescription Management
Customer Service Dept.
P.O. Box 746000
Cincinnati, OH 45274-6000 Fax: 800-600-4829

Note: Anthem health plans and many groups under those plans vary considerably in what clinical services and programs they apply. For instance, Maine will not apply step therapy protocols to plans in that state.