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ASCRS and Ophthalmic and Specialty Communities Urge CMS to Abandon Plan to Allow Step Therapy in Medicare Advantage

This week, ASCRS joined the American Academy of Ophthalmology, the American Society of Retina Specialists, and several oncology groups in a meeting with CMS to advocate against a recent policy change that would allow Medicare Advantage (MA) plans to use step therapy for Part B drugs administered in the physician’s office. Step therapy, or “fail first,” is a resource management tool that requires a patient to undergo and fail with a less expensive treatment before the insurer will cover a more expensive—and potentially more clinically appropriate—treatment. Previously, MA plans were prohibited from using step therapy; however, this summer CMS announced it would begin allowing it in January 2019. In our meeting with CMS, we stressed that step therapy can lead to patient harm, citing examples from the private insurance market, and argued that CMS does not have the legal basis to allow this in MA, since MA plans must cover the same treatments as traditional Medicare. We will keep you updated.

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