Step therapy expands to Medicare Advantage

The Medicare agency recently announced a change that could impact the ability of beneficiaries to get their physician-administered drugs in a timely manner. 

In August, Medicare expanded the ability of Medicare Advantage plans to use step therapy, or fail-first policies, for drugs that are delivered by a physician in an office setting. (Step therapy is the practice of insurers requiring patients to try other medications first before “stepping up” to the drugs their doctor prescribed.) 

Traditionally, these physician-administered drugs have been exempt from step therapy for those on Medicare. However, starting in January, this new policy could delay access to treatment for the psoriatic disease community and create new barriers to care for patients and providers. 

Medicare Advantage plans, sometimes called Medicare Part C or MA plans, are offered by private companies and operate more like commercial coverage than traditional Medicare. About one-third of all Medicare beneficiaries choose an MA plan, which are required to offer all the same benefits of traditional Medicare (Parts A, B and often Part D). 

While prescriptions drugs that you collect at the pharmacy counter or have mailed to your house have always been at risk for step therapy, these fail-first policies are traditionally not allowed for those drugs that your doctor provides. Unfortunately, that is about to change when the new plan year starts in January. 

(Note: This change only impacts MA policies. If you have traditional Medicare, you will not see new step therapy practices for your Part B drugs.) 

Our continuing struggle with step therapy

As many of you who follow the NPF’s advocacy work know, step therapy reform is one of our biggest priorities. Step therapy creates unnecessary hurdles for accessing critical medications and we are a leader in both state and federal actions to reform these practices. Under step therapy, patients with chronic conditions like psoriatic disease face delayed treatment, increased disease activity and potentially irreversible disease progression. 

If step therapy is allowed in MA plans, seniors and individuals with disabilities could be forced to try a different drug, including a self-injected medication, before the physician-administered drug their doctor thinks will work best for them. This not only disrupts the patient-physician relationship, but also exposes patients with MA plans – who often have fixed incomes – to higher out-of-pocket costs for a less-effective drug. Therefore, our advocacy team has been deeply involved in activities to make sure this new policy is implemented in a patient-friendly way. 

NPF has sent two letters to the Secretary of Health and Human Services Alex Azar to advocate for patient-friendly guidelines for the new system. Our work on federal and state step therapy reform means we have a proven model for an exception process that would ensure patients continue to receive the right medication at the right time. In the first letter, we have put forward details of what this process should look like and asked the Administration to engage with us as they finalize details of the standards MA plans will need to meet. 

In the second letter, we were joined by 39 other patient and provider advocacy groups that share our collective concerns and ideas for a way forward. As a result of these communications, we are set to meet with key leadership at the Department of Health and Human Services this fall to discuss our proposals.

In addition to working directly with the Medicare agency, we have also engaged with our congressional champions to increase pressure for reforms. There is wide bipartisan support in Congress to add increased patient protections into the health insurance plans offered by employers. Many members who support these efforts are now urging the Administration to extend these same protections for Medicare beneficiaries and they are also adding their voices to the conversation. 

While this policy has only been recently announced, we are hopeful that Medicare Advantage beneficiaries will see some increased protections in the new year. We will continue to keep you updated on our advocacy activities. If you have questions about your individual MA plan and access to specific medications, please contact our Patient Navigation Center for assistance. 

Driving discovery, creating community

For more than 50 years, we’ve been driving efforts to cure psoriatic disease and improve the lives of those affected. But there’s still plenty to do! Learn how you can help our advocacy team shape the laws and policies that affect people with psoriasis and psoriatic arthritis – in your state and across the country. Help us raise funds to support research by joining Team NPF, where you can walk, run, cycle, play bingo or create your own fundraising event. If you or someone you love needs free, personalized support for living a healthier life with psoriatic disease, contact our Patient Navigation Center. And keep the National Psoriasis Foundation going strong by making a donation today. Together, we will find a cure.

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