The Academy orchestrated a unified response by ophthalmology this week in our latest effort to halt federal fail-first policies that will hurt Medicare Advantage’s beneficiaries by delaying necessary care. In comments to the Centers for Medicare & Medicaid Services, an Academy-led coalition, including the American Society of Cataract and Refractive Surgeons, the American Glaucoma Society, the American Society of Retina Specialists and the Retina Society, believe that the agency’s implementation of step therapy is unacceptable.
Our coalition contends that CMS is failing to do enough to ensure that step therapy will not impede patients’ timely access to Part B drugs. Additionally, a united profession of ophthalmology is again challenging the legality of the policy. It is our longstanding belief that CMS lacks the authority to permit its Medicare Advantage plans to impose such a coverage tool.
Medicare Advantage plans are now allowed to force step therapy for beneficiaries, a change that took effect at the beginning of the month. CMS is permitting Medicare Advantage plans to require that patients’ treatment start with a drug chosen by the health plan — even an off-label option.
Our coalition letter to CMS Administrator Seema Verma raises several critical points that justify the immediate halt of step therapy in Medicare. First, the concept of step therapy is antithetical to the requirement that Medicare Advantage plans provide equal access to and coverage of Part B drugs as original Medicare. Second, CMS’ proposals are inadequate to ensure that imposition of step therapy will not interfere with access to Part B drugs.
The agency says that step therapy allows Medicare Advantage plans the ability to negotiate drug prices, which could lower costs. However, the Academy believes that it inserts substantial obstacles between patients and their physicians’ recommended treatment options.
