Medicare Advantage

TAKE CARE: Advocacy Blog Series Medicare Advantage Plan Change Coming in 2019

Considering a Medicare Advantage plan for 2019?

An important change is coming that you should know about!

The administration recently released guidance that allows Medicare Advantage (MA) plans to use step therapy. This is new for next year and a few health insurers have already said they will institute the policy. In this week’s Take Care blog, we break down the issue to help you make the best choice during open enrollment season. Remember: Medicare open enrollment has already started and continues through December 7. Read on to get the scoop on this change to Medicare Advantage plans.

What is step therapy?

Step therapy is a practice used by insurers that sometimes requires people to try lower-cost medications before allowing more expensive treatments, despite a physician’s recommendation. Step therapy is often called “fail first” since patients must “fail” to get better on the cheaper drugs before “stepping” up to the drug their doctor had originally prescribed.

Why are Medicare Advantage plans allowed to use step therapy? What types of drugs are affected?

Beginning on January 1, 2019, Medicare Advantage – the private insurance alternative to traditional Medicare – will be allowed to implement step therapy policies for drugs you receive in your doctor’s office such as infusions. If you are enrolled in a Medicare Advantage plan, this means your infusion may not be the insurance company’s first choice to treat your disease; they may require you to try a lower cost alternative that hasn’t worked for you in the past.

What if I am already stable on my infused medication? Does this mean I have to change therapies?

Not necessarily. The guidance issued by the administration to Medicare Advantage plans states that the step therapy policy must only apply to new prescriptions for drugs that you have not previously used before. The guidance also requires patients to receive an expedited appeals process.

Although it sounds like the guidance provides a degree of comfort – especially if you are already doing well on an infused medication – it is unclear how Medicare Advantage plans will implement this policy, and whether they will follow the guidance issued by the administration. Further, the guidance does not require Medicare Advantage plans to share information with Medicare about how patients are affected by the new change. This means it will be difficult to understand the scope of any patient access issues if and when they arise.

Have any Medicare Advantage plans announced they will implement this policy?

Starting in January, three private insurers that offer Medicare Advantage plans have said they will apply step therapy requirements to specialty drugs when you visit the doctor’s office. These insurers are Aetna, Humana, and United Healthcare.

I’m currently considering my Medicare options for open enrollment. Do you have any tips?

Many important questions to consider are available in the Foundation’s Your Coverage, Your Care toolkit – a newly updated and comprehensive tool to help you navigate health care choices. But here are a few actions you can take right now if you are exploring a Medicare Advantage plan this open enrollment season:

  • Carefully compare Medicare Advantage plans during open enrollment and check to see if your drug is covered and whether step therapy will apply.
  • Remember: Medicare Advantage plans offered by Aetna, Humana, and UnitedHealth Care have already said they will use step therapy beginning next year. If you were enrolled in one of these Medicare plans last year, it is important that you carefully scrutinize the plan before you re-enroll. In particular, be on the lookout for any changes to the drug formularies. You can learn more about formularies and drug coverage in our toolkit here.

How is the Arthritis Foundation taking action on the step therapy guidance?

The Arthritis Foundation is raising awareness about the policy with lawmakers in Washington. Our priorities are to ensure the step therapy guidance is implemented appropriately and with sufficient patient guardrails. A cornerstone value of the Foundation is that patients who are stable on medication should be able to remain on that medication – without fear of being forced to switch unexpectedly or face delays in treatment. It’s a principle that is guiding our advocacy on this new change.

What resources are available from the Arthritis Foundation?

The Arthritis Foundation has kicked off our open enrollment season to raise awareness of your health care choices for 2019. Visit our Your Coverage, Your Care toolkit, a great resource to help you understand your insurance options, the claims and appeals process, and tips to overcome barriers.

Additionally, if you have any questions about your health care, we have licensed clinical social workers on staff that can talk with you 24 hours a day for your convenience. You can reach the Arthritis Foundation Helpline at 1-844-HELP (4357).

If you’d like to stay informed of federal and state-based health care issues, consider signing up to be an Advocate. Becoming a part of our Advocacy grassroots network is an easy way to get involved and stay informed.

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