AAO calls for elimination of step therapy protocols during pandemic
Step therapy protocols and prior authorization regulations in Medicare Advantage and Part D plans are limiting access to needed medications and should be suspended by CMS for the duration of the COVID-19 pandemic, according to the clinical spokesperson for the American Academy of Ophthalmology
“The Academy has requested there be an immediate suspension of all step therapy requirements by Medicare Advantage plans and, in fact, by all commercial carriers as well,” George A. Williams, MD, told Healio/OSN.
A CMS spokesperson told Healio/OSN the organization officially suggested Medicare Advantage plans be more flexible during the pandemic in response to the AAO request.
“CMS also encouraged Medicare Advantage plans to utilize the flexibility of waiving or relaxing plan prior authorization requirements at any time in order to facilitate access to services with less burden on beneficiaries, plans and providers. Any such relaxation or waiver must be uniformly provided to similarly situated enrollees who are affected by the disaster or emergency,” the spokesperson said.
The spokesperson said CMS also mandated Medicare Advantage plans may not impose any prior authorization for the coverage of testing and testing-related services for COVID-19 on or after March 28, 2020, the spokesperson said.
The response from CMS was a disappointing one and will likely have little effect on Medicare Advantage plans eliminating step therapy protocols, Williams said.
The practice of step therapy, in which patients must try one or more less costly medications specified by an insurance company before moving on to a more expensive medication, is a reality for all ophthalmologists. It creates unnecessary hurdles for patients to access needed medications, Williams said.
“In the best of circumstances, this is an administrative nightmare. Now during the pandemic, it has become something simply impossible to perform,” he said.
For example, under step therapy protocols, many Medicare Advantage and Part D plans would require a patient first fail off-label bevacizumab before qualifying for longer-lasting aflibercept to treat retinal diseases, Williams said.
To prove a therapy has failed, practice employees need to follow patients from the initiation of the therapy and work closely with them to see how they respond to the drug.
“It’s the exact wrong approach in a pandemic. We want to use drugs that are FDA approved, some of which have FDA approvals for longer periods of time that would allow us to treat these patients and minimize their need to return to the office for follow-up appointments,” he said.
Practices are operating with minimum staffing during the pandemic and cannot be expected to spend hours on the phone working with drug carriers and insurance representatives to receive new drug approvals for patients, Williams said. – by Robert Linnehan
Disclosure: Williams reports no relevant financial disclosures.