Step Therapy

ASRS opposes step-therapy protocols that require patients to try and fail certain treatments before allowing access to other, potentially more appropriate treatments. We are particularly concerned about step-therapy policies that require the off-label use of Avastin when branded drugs (Eylea® and Lucentis®) are available as it undermines the authority of the Food and Drug Administration.

The most appropriate course of treatment for a given medical condition depends on the patient’s unique clinical situation. While a particular drug or therapy might be generally considered appropriate for a condition, the presence of comorbidities, potential drug-drug interactions, or patient intolerances, for example, may necessitate the selection of an alternative drug as the first course of treatment. Step-therapy requirements interfere with medical decision-making and often delay getting patients the right treatment at the right time. For some patients, this could result in unrecoverable sight loss. 

Despite our long-standing opposition, the Centers for Medicare and Medicaid Services (CMS) in an August 7, 2018 memo to Medicare Advantage (MA) Organizations entitled “Prior Authorization and Step Therapy for Part B Drugs in Medicare Advantage,” rescinded its September 17, 2012 memo prohibiting MA plans from using step therapy for Part B drugs. If the controversial plan stands, Medicare Advantage plans would be allowed to utilize step-therapy protocols for physician-administered drugs covered under Medicare Part B beginning in 2019.

ASRS is actively and vigorously opposing this change as it undermines patient-physician decision-making and creates dangerous barriers and delays to effective care, especially for the sickest patients. 


Advocacy Timeline

  • In May 2018, ASRS sent letters to Magellan, a benefit management company, and Kaiser Foundation Health Plan challenging  their roll-outs of Avastin-first policies.
  • In April 2018, ASRS sent letters to Blue Cross and Blue Shield of Tennessee and Providence Health Plans to oppose policies that require physicians to use Avastin first. 
  • In 2017, ASRS wrote letters to Blue Cross and Blue Shield regarding its Federal Employee Benefits Program and to Highmark regarding its intravitreal injection medical policies.
  • In 2014, ASRS sent a letter to Humana to oppose its step-therapy policy aimed at restricting the use of medications to treat age-related macular degeneration (AMD) and other retinal diseases. The letter corresponded with the ASRS Buyer Beware Campaign, an effort to encourage members to discuss step-therapy policy changes with patients enrolled in Humana’s commercial plans so they would know their plans had instituted barriers to accessing the FDA-approved treatments vital to saving their sight.

 You can view additional letters that ASRS has sent to payors to guide the development of your own letters opposing these policies.

Please contact monica.horton@asrs.org if you have evidence that an insurance plan is enforcing a step-therapy policy or is restricting beneficiaries’ access to Part B drugs or services.

 

 

 

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