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CMS rule enables MA plans ability to use step therapy

05/30/2019 8:33 AM | Rebekah Francis (Administrator)

The Centers for Medicare & Medicaid Services (CMS) issued a final rule enabling Medicare Advantage (MA) plans to implement step therapy for Part B drugs as a recognized utilization management tool. CMS did however, put some parameters on how step therapy may be implemented by these plans. Starting Jan. 1, 2020, MA step therapy programs:

·     Only apply to new starts of medication;

·     Must be reviewed and approved by the plan’s pharmacy and therapeutics committee; and 

·     Must have a shorter decision-making time frame when patients request coverage of or appeal a denial of a Part B drug. 

The rule also codified the longstanding policy that Part D sponsors are permitted to implement prior authorization and step therapy requirements for beneficiaries starting treatment for five of the six Part D drug classes.


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