CMS Allows Medicare Advantage Plans to Implement Step Therapy Prior Authorization Requirements

Pill_handThe Centers for Medicare and Medicaid Services (CMS) has announced that it is rescinding guidance issued in September 2012 that prohibited Medicare Advantage (MA) plans from using step therapy for Medicare Part B drugs.

Starting Jan. 1, 2019, MA plans will have the option of implementing step therapy to manage Part B drugs. Step therapy is a type of prior authorization for drugs that begins with the most preferred drug therapy for a medical condition and then progresses to other therapies only when necessary.

Physicians and practices should be aware that ongoing Part B drug therapies will not be affected by the new requirements. Step therapy can only be applied to new prescriptions or administrations of Part B drugs for beneficiaries that are not actively receiving the affected medication. CMS says that no beneficiary receiving drugs under Part B will have to change their medication.

Other noteworthy provisions in the policy include:

  • If a beneficiary is enrolled in a plan offering step therapy, they can ask the MA plan for an expedited exception if they believe they need direct access to a drug that would otherwise only be available after trying an alternative drug. CMS says that exception requests will be completed as expeditiously as the beneficiary’s health condition requires, generally within 72-hours.
  • If a plan decides to offer step therapy in 2019, the plan must provide communication to beneficiaries through the Annual Notice of Change and Evidence of Coverage documents. Patients that do not wish to participate in a plan that offers the option of step therapy will have the ability to select a different plan.
  • MA plans that offer step therapy will be required to implement care coordination services for beneficiaries as part of a drug management care coordination program. This includes discussing medication options with beneficiaries, providing educational material, and implementing drug adherence strategies.

CMS offers more details on the policy in this letter from CMS to MA Organizations.

Pennsylvania Medical Society (PAMED) members with questions can also contact our Knowledge Center at 855-PAMED4U (855-726-3348) or KnowledgeCenter@pamedsoc.org.

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