A study by Avalere reveals that health insurers are increasingly delaying and denying drugs to cancer patients through the use of step therapy, reports Noah Tong for Fierce Healthcare.
The American Cancer Society Cancer Action Network (ACSCAN) released a paper that demonstrates Medicare Advantage insurers are weaving step therapy into their prior authorization requirements. Sometimes, enrollees don’t even realize it. Step therapy is a means by which insurers require patients to use a less costly treatment before receiving a more costly one, such as requiring an X-ray before approving a CT scan or MRI.
Some say that requiring prior authorization for cancer drugs helps ensure safety. Prior authorization can also save patients money. But, what the Medicare Advantage insurers are doing is troubling. Patients and doctors are too often unaware of what the insurers are requiring. In particular, delays in treatment are concerning.
Kisqali and Verzenio are two breast cancer drugs for which Medicare Advantage insurers often require step therapy. They won’t cover these drugs unless other less costly drugs are shown to be ineffective. One concern is “embedded step therapy,” which could hide an insurer’s use of step therapy. It might not be included in an insurer’s Part D list of covered drugs.
In the year between 2023 and 2024, overall, Medicare Advantage insurers used step therapy more often for breast cancer drugs and hepatocellular carcinoma, according to the American Cancer Society. Medicare Advantage insurers required step therapy as much as 95 percent of the time. They did not appear to require it for biosimilar drugs Kanjinti and Trazimera.
The bigger insurers tend to require step therapy more of the time than the smaller insurers. If the issue is truly safety, they should be using step therapy with the same frequency.
To date, the Centers for Medicare and Medicaid Services, CMS, which oversees the Medicare Advantage plans, has allowed insurers to decide for themselves when to use prior authorization. Some use it a lot more than others, at times delaying and denying urgently needed care inappropriately.
Prior authorization determinations should be standardized across all Medicare Advantage plans. Without standardization, people cannot meaningfully distinguish among MA plans. Moreover, MA plans can wrongly deny or delay care with little if any accountability.
Here’s more from Just Care:
- OIG finds widespread inappropriate care denials in Medicare Advantage
- Medicare Part D drug coverage stunts are rampant
- Billions in Medicare savings from Medicare drug price negotiation by 2031
- Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
- CVS plans to raise Medicare Rx premiums a lot in 2025
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