CMS Gives Medicare Advantage Plans Option to Utilize Step Therapy

Starting January 1, 2019, the Centers for Medicare & Medicaid Services (CMS) is giving Medicare Advantage (MA) Plans the option to utilize step therapy for Part B drugs. For example, in 2019, MA Plans may now require that a beneficiary who is newly diagnosed with a condition begin treatment with the plan's most preferred, most cost-effective drug therapy before progressing to a more costly drug therapy if the initial treatment is ineffective. This change will only apply to newly prescribed medications. 

As part of the policy announced on August 7, 2018, Medicare Advantage plans that also offer a Part D benefit will be able to cross-manage across Part B and Part D. 

Medicare Advantage plans that choose to offer this approach to enrollees in 2019, must explicitly communicate this to beneficiaries through the Annual Notice of Change and Evidence of Coverage documents. Patients that do not want to participate in a plan that elects to adopt this step therapy approach will have the option to select a different plan.

The ACCC policy team is currently analyzing this policy change and will provide an update to members.

Read CMS memo to Medicare Advantage plans.

Read CMS fact sheet on Medicare Advantage Plans and step therapy for Part B drugs.

Posted 8/7/2018