Medical Bag Contributing Writer June 5, 2019
After an August 2018 proposal, the Centers
for Medicare and Medicaid Services (CMS) have
released their final ruling on Medicare Advantage and Part D Drug Pricing.
Included within this rule is a provision allowing Medicare Advantage plans
physicians to force physicians (or patients) to use step therapy for Part B
drugs, according to a press release by the American College of Rheumatology
(ACR).
This change in policy differs from the
original proposal and addresses several of the primary concerns raised by the
ACR.
“We were pleased to see that CMS included the
ACR’s suggestion to implement a 365-day ‘lookback’ period for Part B therapies
to determine if the enrollee has been actively taking a Part B medication,”
said Angus Worthing, MD, chair of the ACR’s Government Affairs Committee, in a
press release.
This is an improvement on the initially
suggested 108-day lookback, which, Dr Worthing noted, would have put many
patients at risk of having to “go through step therapy all over again.”
Despite these positive changes, the ACR
continued to push for clarity and transparency for patients. Specifically, the
ACR has requested that CMS “require [Medicare Advantage] plans to make the step
therapy exception process readily available and understandable on its website
for providers, patients, and caregivers.”
Also finalized were regulations relating to
the Medicare Part D Explanation of Benefits, which requires the “inclusion of
drug pricing information and lower-cost therapeutic alternatives in the
Explanation of Benefits that Part D plans send members.”
Although Dr Worthing acknowledged this
information is helpful and should be available to patients, he cautions that
the ACR would not support this information being used to force an otherwise
stable patient to switch biologic medications in the interest of cost control.
According to the press release, the ACR hopes
that CMS will closely monitor plans for nonmedical switching and will encourage
continued transparency about utilization management requirements.
Reference
ACR. American College of
Rheumatology statement on CMS Medicare Advantage final rule [press
release]. Atlanta, GA: American College of Rheumatology; 2019. . Published May
17, 2019. Accessed May 21, 2019.
This article originally appeared on Rheumatology Advisor
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