Health Insurance Managed Care Medicare Advantage Pharmaceuticals

What will happen when step therapy comes to Medicare Advantage?

CMS recently authorized Medicare Advantage (MA) plans the ability to apply step therapy protocols to Part B drugs.  Although it is not clear the degree to which the MA plans will implement step therapy, a good guide is to see what is happening in the commercial insurance market.  A Health Affairs blog by Chambers, Panzer and Neumann attempts to answer this question using the Specialty Drug Evidence and Coverage (SPEC) Database.  The authors describe these data as follows:

Information in SPEC is extracted from publicly available coverage decisions issued by 17 of the 20 largest commercial health plans relevant to their commercial lines of business…[using these data], we found wide variation in the frequency with which health plans apply step therapy protocols in their specialty drug coverage decisions, ranging from 2 percent to 49 percent across the included plans.

Not only is there wide variation in the use of step therapy across plans (the extensive margin), how step therapy is applied also varies (the intensive margin).

For example, of the 1,208 coverage decisions that include a step therapy protocol, …63 percent…require patients to step through a single therapy, while…37 percent…require stepping through multiple therapies. Moreover…15 percent…of protocols include three or more steps, and some require patients to fail up to five treatments before patients can gain access to a particular therapy.

The article also notes wide variability of how step therapy is applied.  Generally, step therapy is less common among oncology treatments and orphan drugs.

1 Comment

  1. Allowing step therapy for doctor-administrated drugs represents a significant change, especially since this class of medication is often used in treatment of critical ailments like Cancer. Patients will be empowered with more choices.

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