• Loss of ‘15 Letters of Visual Acuity’: One Medicare Advantage Plan’s Definitions of Step Therapy Failure


    The Academy is uncovering the dangerous lengths to which Medicare Advantage plans will use step therapy to deny necessary eye care to our patients. The Centers for Medicare & Medicaid Services now permits Medicare Advantage plans to use fail-first policies for Part B drugs. A Medicare Advantage plan serving Idaho, Montana and Oregon defines an anti-VEGF drug’s failure as resulting in patients’ worsening vision after a minimum three-month trial, “such as losing greater than 15 letters of visual acuity.”

    At least eight other Medicare Advantage plans are implementing step therapy to curtail physicians’ choice in 2019 when treating patients. Many requirements for intravitreal anti-VEGF therapy are similarly egregious. Some require three months of failed treatment before the physician can administer a different drug. 

    You can help bolster our advocacy efforts by relaying your patients’ negative experiences with step therapy on this website. We’re not just looking for Medicare cases. We’re equally interested in understanding how commercial plans’ use of step therapy has affected our patients.

    In addition to sharing your patients’ stories through the portal that the Academy and Prevent Blindness partnered to build, you can urge your patients to tell their own stories on the same website.

    As an alternative, email your story to the Academy at healthpolicy@aao.org. We’ll follow up with you for more details, but at the very least, give us the following details:

    • The condition you treated
    • The medication that was first recommended and then denied
    • The reason for the denial
    • The case’s outcome

    These stories are critical to our ability to convince the executive branch that step therapy interferes with the patient-physician relationship, that fail-first policies in ophthalmic eye care are bad and that our patients suffer the consequences of a misguided attempt to bring private-sector tools to federal entitlement programs.