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.