Effective January 1, 2019, Medicare Advantage Plans may use step therapy for Medicare Part B-covered drugs. Step therapy is a utilization management tool that allows a plan to require an enrollee to try a different, less expensive drug that treats the same condition before it will cover a more expensive drug.

Previously, the Centers for Medicare & Medicaid Services (CMS) prohibited imposing a step therapy requirement on Part B-covered drugs. CMS rescinded this decision, claiming to want plans to have more flexibility to negotiate lower drug prices from pharmaceutical companies.

Read on for more information, provided for us by the Medicare Rights Center.

Part B coverage of prescription drugs

While Medicare Part D covers prescription drugs in most cases, there are circumstances where drugs are covered under Part B.

• Part B covers most drugs administered by a provider or at a dialysis facility, but the provider or facility must supply AND administer the drug, and the drug cannot be one that is “usually self administered”—for example, one that is taken orally. Part B also covers some outpatient prescription drugs, mainly oral cancer drugs (chemotherapy).
• Part D covers most outpatient prescription drugs (drugs received at a pharmacy).
• There are a few drugs that can be covered by either Part B or Part D, depending on the circumstances.

Step therapy for Part B-covered drugs

Part B step therapy means that a plan may require an enrollee to use a plan-preferred Part B drug before using a different Part B drug. Additionally, Medicare Advantage Plans that include prescription drug coverage may require a beneficiary to use a Part D drug before using a Part B drug, or vice versa. Plans are required to inform beneficiaries of any Part B step therapy requirements in their Annual Notice of Change (ANOC) and Evidence of Coverage.

A Medicare Advantage Plan that chooses to use step therapy for Part B-covered drugs is also required to offer a drug management care coordination program for affected enrollees. Such programs must provide:

• Interactive medication review and consultation activities for beneficiaries
• Educational materials to inform beneficiaries about drugs within the program
• Medication adherence strategies to help beneficiaries with their drug treatment

Plans may offer rewards to encourage participation in their drug management program, but beneficiaries are not required to participate. Beneficiaries who are already taking a Part B-covered medication cannot be required to switch to their plan’s preferred drug. Plans can only impose Part B step therapy when a
current or new enrollee starts a new medication.

Exception requests and appeals

Beneficiaries have the right to request an exception to their Medicare Advantage Plan’s step therapy requirement. An exception request allows a beneficiary to ask their plan to cover their drug as an exception to its rules. If their exception request is denied, they may begin a formal appeal. A beneficiary may request that their appeal be decided on an expedited timeline if their doctor feels that their health could be seriously harmed by waiting the standard amount of time for a decision.

Before you can start your appeal, you will need to receive an official written decision from your plan, called a Notice of Denial of Medical Coverage. Start your appeal by following the instructions on this notice. If you have additional questions about the appeal process, contact your State Health Insurance Assistance Program (SHIP) for free information and assistance.