After an August 2018 proposal, the Centers for Medicare and Medicaid Services (CMS) have released their final ruling on Medicare Advantage and Part D Drug Pricing. Included within this rule is a provision allowing Medicare Advantage plans to force physicians (or patients) to use step therapy for Part B drugs, according to a press release by the American College of Rheumatology (ACR).
This change in policy differs from the original proposal and addresses several of the primary concerns raised by the ACR.
“We were pleased to see that CMS included the ACR’s suggestion to implement a 365-day ‘lookback’ period for Part B therapies to determine if the enrollee has been actively taking a Part B medication,” said Angus Worthing, MD, chair of the ACR’s Government Affairs Committee, in a press release.
This is an improvement on the initially suggested 108-day lookback, which, Dr Worthing noted, would have put many patients at risk of having to “go through step therapy all over again.”
Despite these positive changes, the ACR continued to push for clarity and transparency for patients. Specifically, the ACR has requested that CMS “require [Medicare Advantage] plans to make the step therapy exception process readily available and understandable on its website for providers, patients, and caregivers.”
Also finalized were regulations relating to the Medicare Part D Explanation of Benefits, which requires the “inclusion of drug pricing information and lower-cost therapeutic alternatives in the Explanation of Benefits that Part D plans send members.”
Although Dr Worthing acknowledged this information is helpful and should be available to patients, he cautions that the ACR would not support this information being used to force an otherwise stable patient to switch biologic medications in the interest of cost control.
According to the press release, the ACR hopes that CMS will closely monitor plans for nonmedical switching and will encourage continued transparency about utilization management requirements.
ACR. American College of Rheumatology statement on CMS Medicare Advantage final rule [press release]. Atlanta, GA: American College of Rheumatology; 2019. . Published May 17, 2019. Accessed May 21, 2019.