• Background

    Step therapy, also known as "fail first" therapy, requires patients' care to begin with health plans’ most-preferred drug therapy, and physicians are allowed to select alternatives to the preferred drug only under defined circumstances.

    Step therapy is already used by private payers, to questionable results. But to adopt such a policy for Medicare Advantage, which applies to nearly a third of Medicare’s total patients, is a major move that the Academy opposes. The Academy also questions the proposal’s legality.

    The policy change took effect Jan. 1, 2019 as part of a Medicare Advantage patient-centered care program.

    Medicare Advantage plans in Idaho and Oregon have already implemented what we would consider the most egregious of these policies. In one example, one plan defines a 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.”

    Academy President Calls on Ophthalmologists to Act on Step Therapy

    Academy President George A. Williams, MD, discusses the importance of acting against step therapy. Learn what the Academy is doing and read what you can do to send a message about step therapy to decision-makers.

    Academy position

    Step therapy is designed to rein in health care costs. But it also has many unintended consequences, including:

    • Delayed access to necessary, optimal treatments
    • Massive administrative burdens
    • A nonphysician middleman dictating how to treat patients

    What we’re doing

    The Academy works directly with state ophthalmological societies to protect physicians' rights to treat patients as they see fit. We're educating legislators and regulators on the dangers of fail-first care for eye disease. The Academy in 2014 argued successfully against step therapy’s legality. It was based on a 2012 CMS memo that concurred with our legal assessment. 

    What you can do

    Your patients’ experiences with step therapy are urgently needed to demonstrate how “fail-first” policies are putting our patients’ health at risk. The Academy is calling for your stories of cases where step therapy is being used to the detriment of our patients’ care.

    Medicare Advantage plans in Idaho and Oregon have already implemented what we would consider the most egregious of these policies. In one example, PacificSource defines a 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.”

    This is unacceptable.

    You can help bolster our advocacy efforts by relaying your patients’ negative experiences with step therapy on this survey or by emailing healthpolicy@aao.org. 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.

    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 Trump administration 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.

    Resources