The following is today’s press release from the American College of Rheumatology:
- Make clear that a patient’s provider must determine if a patient “fails” a treatment. This decision should not be made by another entity such an insurance company.
- Provide exceptions to step therapy if:
- The treatment is contraindicated for a patient’s specific condition.
- The provider determines, based on medical evidence, that the treatment is likely to be ineffective, likely to cause a harmful reaction, or impede the patient’s ability to perform daily activities or responsibilities and/or adhere to the treatment plan.
- The provider believes the new treatment will put the patient’s life in jeopardy or irreparably harm his/her physical or sensory functions.
- Require MA plans to disclose that Part B drugs may be subject to step therapy in the plan’s Annual Notice of Change and Evidence of Coverage Documents.
- Implement a 365-day “lookback” period for Part B therapies instead of the current 108-day period used in Medicare Part D plans.
- Preclude plans from implementing step therapy via a different utilization management process such as prior authorization.
- Increase monitoring of plans’ usage of utilization management practices and require that all denials include the clinical rationale for the decision while making clear a beneficiary’s appeal rights.