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ASCRS, the Alliance of Specialty Medicine, and the Medical Community to Express Concern on the Administration’s New Policy to Allow Step Therapy in Medicare Advantage Beginning in January 2019

As we alerted you this week, CMS announced it has reversed its existing policy and will now allow Medicare Advantage (MA) plans to use step therapy for new prescriptions beginning in January 2019. Step therapy is a cost-containment strategy that requires physicians to prescribe an insurer’s preferred treatment first, and only covers more expensive treatments if the patient does not respond to the initial treatment. The new guidance also permits MA plans that offer Part D drug coverage to use step therapy to require a Part D drug prior to using a Part B drug, or vice versa. Plans’ use of step therapy must continue to comply with national and local coverage determinations. In addition, the policy requires MA plans to notify beneficiaries if they intend to use step therapy in a plan, but may provide incentives or rewards, such as gift cards, in exchange for participation.

ASCRS, and our coalition partners in the Alliance of Specialty Medicine and the medical community, are concerned this policy change could potentially limit access to care for beneficiaries. In response to this announcement, we are developing letters that will outline our concerns and demonstrate the potential impacts to ophthalmology and other specialties. We will keep you updated.