Boeing Co. engineers may have been surprised to find out Wednesday that after April 3 getting cholesterol-fighting drugs for the first time could be a lot more complicated. But it was no surprise to many doctors and pharmacists.

Regence BlueShield, a major provider of health insurance in Washington, said it is notifying area members this week that to get Lipitor, a very expensive, aggressively marketed and highly prescribed anti-cholesterol drug, they'll first have to try less-expensive generic and brand-name drugs.

The change was news to Bill Dugovich, a spokesman for the Boeing engineers union. About half its members are insured through Regence.

"This is disappointing not to hear from Regence or Boeing on this," Dugovich said.

"There are some categories in our policies right now that encourage generics," said Kristin Farr, benefits specialist for the Society of Professional Engineering Employees in Aerospace at Boeing. But she wasn't aware of the change involving Lipitor.

In 2006, Regence began a step program for heartburn medications, spokesman Charlie Fleet said, and it is looking at antidepressants for similar treatment.

"But we have no timeline," Fleet said.

Jim Carlson, director of clinical pharmacy services at Group Health, said generic drugs have become more and more available in the past five years. Cholesterol drugs, antidepressants and heartburn medications are just three categories with several generic options.

"Insurance plans are pushing patients into these choices because all of the drugs in that class are equally safe and effective," Carlson said. "It only makes sense to start with the most cost-effective choice."

Dr. W. Hugh Maloney, president of the Washington State Medical Association, said step therapy is not new and is practiced by many health organizations.

Maloney said Lipitor was one of the first cholesterol drugs to be marketed in a category called statins. It was more effective than anything on the market when it came out. It covered more cholesterol disorders.

But, about the same time, Zocor and other similar drugs came on the market. Maloney said. As research showed that there was evidence that other statin drugs were effective, it became appropriate to switch.

"This is going to happen all the time, and it should," Maloney said.

Although switching is cost-effective for insurance companies, it is burdensome for physicians and patients, Maloney said. Doctors, for example, have to know the formulary (drugs authorized by an insurance company) for every insurance plan used by patients. Typically, this could be 18 to 20 formularies, he said. If a doctor wants to prescribe a drug and it's not in the formulary, permission must be sought and granted.

"It's a mother-may-I proposition," Maloney said.

It means filling out forms, being on hold and exchanging faxes -- a waste of time and money, he said.

Carlson at Group Health said step therapy has been practiced there since its founding in 1946. He said it's a basic model of using the most cost-effective medications to achieve high-quality clinical care. Group Health does it in all areas of medicine.

"There are very few therapeutic categories where there are only brand names," Carlson said.

Maloney said that based on evidence, there will be more tiering of prescription drugs, and it's perfectly reasonable if both the patient and physician have easy access to information about drugs and formularies.

"Expect it in more areas," Maloney said. "It's all part of the changing health scene."

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