Access and Coverage
Medicare – Policy Resources

Step Therapy on Part B Drugs in Medicare Advantage Plans

Step therapy is a form of utilization management employed by insurance plans to control costs on pricey drugs and treatments. Typically, step therapy policies require patients to try the cheapest covered drug (regardless of its effectiveness in treating a condition or what the patient’s preferred provider has prescribed) and demonstrate over a course of treatment that the drug is ineffective in treating their condition before they can receive coverage for a pricier medicine or treatment.

Step therapy is especially problematic for patients who live with progressive vision loss that could result in permanent vision impairment. Step therapy policies run the risk of allowing a patient’s vision to worsen while preventing them from receiving the treatment that could be the most effective in slowing disease progression. These patients often do not have the luxury of time to satisfy insurer requirements for coverage. In addition, step therapy policies don’t necessarily consider a patient’s experience with a less-preferred medication or course of treatment, such as side effects from intolerance to medication or potential drug interactions that may cause additional issues that could have been avoided if the patient had access to the prescription first prescribed by their provider.

In August 2018, the Centers for Medicare and Medicaid Services (CMS) determined that Medicare Advantage plans could employ step therapy protocols on covered Part B drugs and has allowed for step therapy to be used since January 2019. This policy remains in place; however, Prevent Blindness has advocated with a community of patient and provider groups to urge CMS to reverse this decision. Prevent Blindness values the patient/doctor relationship and the need for patient choice in making their own treatment decisions with their provider that are in the best interest of patient health.

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