As a follow-up to our recent meeting with Health and Human Services (HHS) Secretary Alex Azar, ASCRS and AAO reiterated our existing opposition to allowing Medicare Advantage (MA) plans to use step therapy in a joint letter this week. Despite that opposition, we recommended that HHS take steps to ensure several safeguards for patients are in place when step therapy is used. These recommendations are deigned to ensure that patients who are stable on a medication do not have their treatments disrupted; appeal and review decisions are expedited; exceptions to step therapy are available when the physician determines that the less expensive treatment would be ineffective or even harmful to the patient; and step therapy policies are clearly disclosed to beneficiaries.
Furthermore, we express concern that some plans are engaging in “implicit” step therapy, rather than developing stated policies, through the use of prior authorization that denies coverage for certain drugs before less expensive alternatives are used. This implicit step therapy lacks even the basic patient protections HHS has laid out in its first memo from August 2018 authorizing the use of step therapy beginning in 2019, and then in a subsequent proposed rule in November 2018 that codified the use of step therapy. We will keep you updated.