Have a Medicare Advantage plan, or considering one for your 2019 coverage? If so, make sure you know about an important rule change for these private alternative Medicare plans. The change hasn’t received a lot of attention, but could potentially affect the medications you take.

In a ruling released last summer, the Centers for Medicare and Medicaid Services (CMS) will allow Medicare Advantage plans to implement “step therapy” for prescription drugs and injectable medicines starting in 2019. Step therapy, also known as “fail first,” means that patients must try—and fail—with cheaper medicines before their insurance will cover costlier drugs.

The pitfalls of step therapy

Step therapy has been used for years by private insurers and employer-sponsored plans to control the costs of pharmaceutical drugs. Typically, the cheaper meds are older, generic versions, which proponents point out often prove equally effective as costlier therapies.

“If a patient is subjected to a strategy of less effective drugs that leads to multiple flares, he may never recover part of that damage.”
Dr. David Charles, chairman, Alliance for Patient Access

But some patients with serious conditions, such as macular degeneration or cancer, may require newer and more expensive drugs. For especially vulnerable patients, waiting to be prescribed the most effective medications can cause irreversible damage, says Dr. David Charles, chairman of the advocacy group Alliance for Patient Access.

Charles points to patients with multiple sclerosis as an example. “If a patient is subjected to a strategy of less effective drugs first that leads to multiple MS flares, he may never recover part of that damage,” Charles says.

Most private insurers allow doctors to submit an exception request on their patients’ behalf stating that the cheaper drugs would not be as effective.

CMS has said the new rule includes an exemption and appeals process for Medicare Advantage, but details are vague. 

Getting ahead of the change

If you’re already taking a pricey drug, your coverage should continue: Medicare Advantage patients will not be subject to step therapy for any medicines they’ve received in the past 108 days.

If you are shopping for a Medicare Advantage plan during this open enrollment period (ending December 7), however, contact the plans you are considering and ask if they will implement step therapy, and how.

And keep in mind that insurers can make this change to existing Medicare Advantage plans, too. If you’re not changing plans, be sure to check for any notices you receive by mail or email that may describe this change, advises Leslie Fried, senior director of the Center for Benefits Access at the National Council on Aging. Or call and ask them to provide details.

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