Docs push back on step therapy in Medicare Advantage


Key clinical point: Medicare Advantage plans will now be able to implement step therapy on Part B drugs.

Major finding: Only new prescriptions will be eligible for step therapy; existing treatments will not be disrupted.

Study details: CMS made the decision to reverse previously existing policy on step therapy as part of an ongoing effort to help lower the cost of prescription drugs.

Disclosures: There were no relevant disclosures.

Source: Prior Authorization and Step Therapy for Part B Drugs in Medicare Advantage;


Further, the American Gastroenterology Association “is concerned that the proposal could limit access for current and future beneficiaries and could add to the growing regulatory burden that physicians already face,” according to a statement.

Barbara L. McAneny, MD, president of the American Medical Association, said that physicians “are concerned with patients getting the most effective treatment, and step therapy requirements frequently get in the way. ... Physicians have no easy access to patient benefit and formulary information at the point of prescribing, so they will not be able to readily determine which drugs are preferred by their patients’ [Medicare Advantage] plans. This results in treatment delays and unnecessary red tape for physicians and patients.”

The new policy applies to only new prescriptions or administrations of Part B drugs. Patients will not have current treatments disrupted if that drug is not the first drug on the step therapy ladder. Additionally, patients will have the opportunity to make a one-time change in plans during the first quarter annually if they are finding the plan is not working for them. Plan sponsors must disclose that Part B drugs may be subject to step therapy.

Next Article: