In an effort to reduce high prescription drug costs, the Trump administration announced in 2018 a new policy that was effective January 1, 2019, to permit Medicare Advantage (MA) Plans to begin using step therapy for Part B drugs administered in the office or facility. Following the policy announcement, CMS released a final rule, opposed by ASCRS and the medical community, which codifies the use of step therapy in MA plans and expands step therapy and prior authorization in Part D plans effective on January 1, 2020.Issue Brief
How it Impacts You
Step therapy, also known as “fail first,” 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. Previously, MA plans were prohibited from using step therapy; however, as part of the overall effort to reduce the costs of prescription drugs, CMS announced in August 2018 that plans may begin using step therapy for the 2019 benefit year.