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Reconsider MA Step Therapy Policy

Thursday, September 13, 2018   (0 Comments)
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240 Patient & Provider Groups Urge Leaders in Congress to Ask CMS to Reconsider MA Step Therapy Policy

Allowing Medicare Advantage plans to implement step therapy harms patient access and puts insurers in charge of treatment decisions, groups warn

Washington, DC — A broad coalition of 240 patient and provider groups sent a letter organized by the Part B Access for Seniors and Physicians Coalition to Senate and House leaders asking them to urge the Centers for Medicare & Medicaid Services (CMS) to reconsider a proposal to allow Medicare Advantage (MA) plans to implement step therapy to manage Part B drugs. CMS originally announced the proposal in August in a memo to MA plan sponsors.

“The new policy.... is inconsistent with the requirement that MA plans provide coverage consistent with Original Medicare and threatens to restrict access and decrease therapy choices for patients. This could put patients’ health at risk and potentially creates long-term health care issues in the process,” the letter reads. “Absent significant patient protections, we urge CMS to withdraw this memo and reinstate the 2012 memo for the sake of the millions of beneficiaries who rely on Medicare to access needed care.”

Step therapy, sometimes known as “fail first,” is a troubling practice employed by insurers that forces patients to try therapies preferred by the insurance company before being approved for the therapy their doctor prescribed — even when doctors doubt the insurer preferred option will be effective.

For many conditions, treatments must be carefully tailored to a patient’s individual needs and many patients try multiple therapies before finding one that works best for them. Step therapy draws out this process by requiring patients to try older, less expensive medications that may not only be ineffective but could also lead to pain and adverse side effects. Furthermore, it undermines the clinical judgement of healthcare providers and puts insurance companies in control of treatment decisions.

“Policies that sacrifice the health of patients in the hope of cutting program costs undermine the promise Medicare represents for so many individuals,” the letter concludes. “We ask members of Congress to encourage the Trump administration to consider alternative solutions, like clinically appropriate utilization management, that instead utilizes evidence-based guidelines designed with the input of medical practitioners, patients and advocates.”

To view the letter to Senate and House leaders, click here.

Download the release.

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