ASRS Physician Choice of Medication Campaign: Assistance Needed
As part of the ASRS Physician Choice of Medication Campaign, ASRS needs your assistance in identifying Medicare Advantage plans that have explicit step-therapy policies or that systematically deny the use of Lucentis or Eylea until Avastin has been tried first.
CMS has reminded Medicare Advantage Organizations that “the imposition of additional requirements for access to certain Part B drugs or services, such as step-therapy requirements, is not permitted unless also required through Original Medicare.”
Because Medicare does not have a step-therapy requirement for anti-VEGFs, Medicare Advantage plans cannot establish their own policy. While pre-authorization may be required, the plan may not routinely deny the use of a Part B drug for cost containment purposes.
Sample letters to third-party payers
Requiring off-label use of Avastin before FDA-approved agents
ASRS letters opposing higher standards for the use of FDA-approved drugs for specific indications (ie., Eylea, Lucentis, and Macugen) than for “off-label” compounded Avastin.
- Humana, Louisville, Kentucky (Follow up letter) - February 4, 2015
- Humana, Louisville, Kentucky – December 17, 2014
- Blue Care Network, Southfield, Michigan – March 4, 2014
- Avesis, Phoenix, Arizona – February 26, 2014
- Wellmark Blue Cross and Blue Shield, Des Moines, Iowa – February 15, 2015
- Sample Third Party Payor Letter – March 22, 2013
Report an event
Please contact Jill Blim if you have any evidence that an insurance plan has a step-therapy policy or is restricting beneficiaries’ access to Part B drugs or services.