Advocacy & Practice Updates — Advocacy & Practice

Buyer Beware: Humana’s Step Therapy Policy Blocks Patient Access to FDA-Approved Drugs

Top 10 To Do’s for the New Year

  1. Update your provider designations with all payers that offer retina-specific options
  2. Notify your patients through our Buyer Beware campaign of any changes in their access to FDA-approved drugs and advocate with us for change
  3. Position your practice to meet 2015 PQRS, meaningful use, and Sunshine Act requirements  and avoid future payment reductions
  4. Prepare for vitrectomy procedure payment reductions and watch ASRS for information on procedures undergoing revaluation in 2015
  5. Check for premium designation or other cost and quality-based tiering notices at all office locations (including billing addresses) and let us know if you have
  6. Become an advocate for your patients by signing up to be a Retina Advocacy and Federal Affairs Key Contact
  7. Contact ASRS if you have been affected by network tiering
  8. Register to attend the Practice Management Issues Seminar on March 28-29 in Dallas, TX
  9. Sign up for Retina PractiCare
  10. Look to ASRS as your go-to resource for retina-specific information on how the dynamic payment and delivery environment impacts you and as your trusted advocate for saving sight

December 23, 2014    --    Back to Retina Practice News

Effective January 1, 2015, Humana will begin requiring Avastin before Eylea and Lucentis for all commercial plans. ASRS has sent a letter to Humana detailing our concerns and urging the payer to reverse this improper policy. Together we can continue to fight misplaced payment and coverage policies like we recently did with Aetna.

Informing your patients of the change is critical

ASRS believes it is inappropriate for any insurer to implement any pharmacy or medical coverage policy requiring off-label use of Avastin before an FDA-approved agent (Eylea and Lucentis) will be considered. As part of our Buyer Beware campaign, we encourage you discuss this policy change with your existing and any new patients enrolled in Humana’s commercial plans as soon as possible so they will know that, despite paying their premiums and deductibles, their plan has instituted this barrier to accessing FDA-approved treatments that are vital to saving their sight.

You can protest these polices too

While ASRS strongly urges all insurers to continue allowing retina specialists and their patients to make clinically-driven, patient-centered driven and judicious choices based on each patient’s unique risk factors, clinical appearance, availability of compounded drugs, and financial needs, we anticipate that payers will continue to institute policies like Humana’s and others before them. You can view additional letters that ASRS has sent to payers, which you can also use as an example for your own letter opposing these policies.

Please contact Robbie Gerson if you have any evidence that an insurance plan has a tiered therapy policy or is restricting beneficiaries’ access to Part B drugs or services.

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