Clinical Program Drug Step Therapy – Commercial and Individual Exchange plans, also referred to as UnitedHealthcare Individual & Family ACA Marketplace plans
For fully insured UnitedHealthcare Commercial members in New Jersey, this program is called First Start.
Step programs are targeted towards therapeutic classes that have multiple medication options. While clinical effectiveness may be similar among medication options in a therapeutic class, pricing and factors promoting optimal drug use can vary. Step therapy programs require a trial of clinically appropriate alternative(s) before allowing coverage for the Step 2 medications. Prior to the implementation of a step therapy program, there are several components that are incorporated into its development. This includes, if available, an evaluation of peer-reviewed medical literature which includes randomized clinical trials, drug comparison studies, pharmacoeconomic studies, outcomes research data, published clinical practice guidelines, comparisons of efficacy, side effects, potential for off label use and claims data analysis. Review of step therapy also includes a valuation of benefits, risks, and impacts on members. Step programs are submitted to the UnitedHealthcare Pharmacy and Therapeutics Committee, which includes external physicians representing a broad range of specialties and sub-specialties, medical directors and pharmacists for review and approval prior to implementation.
Several states have enacted legislation requiring that step therapy exception requests (also referred to as step therapy override exceptions) must be approved if the member meets certain conditions or situations. Please contact the OptumRx Prior Authorization department at 1-800-711-4555 or https://professionals.optumrx.com/prior-authorization.html to determine if you qualify for an exception.
UnitedHealthcare makes pharmacy coverage decisions based on an understanding of how our coverage affects total health care. We do this by integrating pharmacy coverage with medical management, accessing information in a database including pharmacy, medical and laboratory data.