Medicare Advantage Step Therapy Proposal Seen as Step Backward for Patients

Some physicians and advocacy groups argue that trying the cheaper drug first might lead to worse outcomes.

Well, here’s a real eye-opener for you: Getting a needle in the eye. Sure, it makes you flinch, but for millions of Medicare beneficiaries getting an injection of Eylea can help them retain vision. As Kaiser Health News reports, Medicare spent $2.2 billion on the drug in 2016 to treat patients with macular degeneration, more than for any other Part B drug.

Richard O’Neal, vice president for market access for Regeneron, which makes Eylea, uses that as an example of how a plan to install a step therapy process into Medicare Advantage could be disadvantageous for patients.

Under step therapy, starting next year, Medicare Advantage plans can require that patients use less expensive Part D and B medications to treat macular degeneration, cancer, and rheumatoid arthritis, among other serious diseases. If those drugs fail, then patients can move on to more expensive medications.

“Some physicians and patient advocates are concerned that the pursuit of lower Part B drug prices could endanger very sick Medicare Advantage patients if they can’t be treated promptly with the medicine that was their doctor’s first choice,” KHN reports.

Or, as O’Neal puts it: “Do you have to lose vision” before you get the most effective medication?

There is an appeals process already in place for beneficiaries denied a specific drug. But only a tiny fraction of Medicare Advantage beneficiaries used it last year, and only one in ten won partial or full decisions, KHN reports.

Sarah Jane Blake, a Medicare counselor for New York’s StateWide Senior Action Council, says that’s “disheartening to say the least. Beneficiaries are intimidated by the hoops they have to go through and often give up trying to purchase the drugs prescribed for them.”