Academy Expands Effort to Educate Congress on Dangers of Step Therapy in Medicare

The Academy is getting congressional gatekeepers up to speed this month on the need to stop step therapy for Medicare Part B drugs. We’ve initiated dozens of meetings with Congress’ physicians, as well as members of committees in the U.S. House of Representatives and Senate who wield Medicare oversight. 

This is a preemptive strike, with more meetings planned, to engage a potent group of allies on the problem with fail-first policies in health care. In doing so, the Academy is laying the foundation for pressure by Congress on the Trump administration to halt its Jan. 1 implementation of step therapy in Medicare Advantage. 

The Academy continues our ongoing conversation with the Centers for Medicare & Medicaid Services to ensure it understands and considers our perspective on step therapy. If those discussions fail, we’re planning to appeal to Congress for a legislative solution. 

The Academy’s actions have new urgency, with the Trump administration recently taking steps to codify step therapy for the Part D program. This tells us that the administration is not inclined to drop step therapy quickly or without a fight. 

Congress’ staffers are an important set of potential allies. They largely serve as the first gate through which a policy idea passes. To help them understand what’s at stake, we’re presenting compelling evidence that shows how CMS’ step therapy initiative is bad for patients, as well as the agency. 

Among the reasons raised by the Academy:

• Step therapy violates the Social Security Act.
• CMS does not have the authority to grant Medicare Advantage plans the ability to limit coverage for Part B drugs.
• The plan interferes with beneficiaries’ access to the same services provided under Original Medicare, which is inappropriate. 

CMS says it will permit Medicare Advantage plans to require that patients’ treatment start with an off-label option, which would include ophthalmic treatments such as Avastin. 

The agency says the proposed policy would allow Medicare Advantage plans greater ability to negotiate drug prices, which could lower costs. However, the Academy believes that it would insert substantial obstacles between patients and their physicians’ recommended treatment options.