CMS Gives Medicare Advantage Plans Option of Using Step Therapy for Part B Drugs

The Centers for Medicare and Medicaid Services (CMS) said that it will give Medicare Advantage plans the option of applying step therapy for physician-administered and other Part B drugs, starting in 2019.

Step therapy is a type of prior authorization for drugs that begins medication for a medical condition with the most lowest-cost drug therapy and progresses to other therapies only if necessary, with the goal of promoting better clinical decisions.

This action, aimed at saving patients money, is part of the Trump administration’s larger agenda to create competition among medications that treat the same conditions.

For the first time, CMS will provide Medicare Advantage plans, which are private health insurance plans that provide Medicare benefits to 20 million Medicare beneficiaries, or a third of all beneficiaries, the option of negotiating for Part B drugs in a way that lowers costs and improves the quality of care, CMS said in a statement.

Medicare Advantage plans that also offer a Part D benefit will be able to cross-manage across Part B and Part D, so that patients receive the best medicine whether it is physician-administered or self-administered, CMS said.

CMS said that the plan paves the way for Medicare Advantage plans to negotiate in a way that ensures patient choice and provides patient protections with guardrails, including that step therapy can only be applied to new prescriptions for patients who are not actively receiving a given medication.

“As soon as next year, drug prices can start coming down for many of the 20 million seniors on Medicare Advantage, with more than half of the savings going to patients," Alex Azar, secretary of the United States Department of Health and Human Services (HHS), said in the statement.

CMS is a federal agency within HHS.

Some reports indicate that the plan could lower drug costs by up to 20%.