Good news: Changes made this summer to physician-administered and Part B medications should result in lower costs for patients.
In August, the Centers for Medicare & Medicaid Services (CMS) announced that it will provide Medicare Advantage (MA) plans the ability to apply step therapy for these drugs in a manner that both decreases costs and improves care for Medicare beneficiaries.
Beginning January 1, 2019, MA plans can use step therapy to manage Part B medications (those you receive at a doctor’s office or hospital outpatient location).
Basically, step therapy means trying lower-priced drugs before trying more expensive medications.
For example: You take a generic drug for a condition and it doesn’t work. The physician prescribes another drug, but that doesn’t work either. The doctor tries a third, more expensive drug, and it works better. You’re informed it requires step therapy.
In order for your insurance plan to cover the more expensive medication, it will see if you’ve tried less expensive alternatives (you did). You must follow the step therapy procedure when required, or your plan may not cover the medication at all.
If the drug does indeed require step therapy, the pharmacist should inform your physician to see if there’s another medication that does not require it.
Part B regulations require Medicare to pay clinicians a certain percentage above the price of drugs given in a physician’s office (including infusions and injections). This formula does not allow for negotiation in the medication prices.
The new guidelines allow patients in MA plans to get better deals as the sales price of Part B drugs may decrease – in turn decreasing copayments made by those with traditional Medicare. MA plans will still cover Part B drugs deemed medically necessary, with step therapy only being applied to new prescriptions of Part B medications for patients not receiving the affected drugs. Thus, no beneficiary currently getting drugs under Part B must change medication.
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