People who take prescription medications on a daily basis to address a medical problem, such as arthritis, asthma, or high blood pressure, are candidates for the step treatment program. It makes it possible for you and your family to obtain the necessary treatment at an affordable cost, while also assisting your business in maintaining coverage for prescription drugs.
What is a step one medication?
Pharmaceuticals in Step 1 are often generic or brand drugs with lower prices that have been shown to be safe, effective, and cost-effective. In the majority of situations, they deliver the same health benefit as a more expensive medicine, but at a far more affordable price.
What is the process of prescription?
What Exactly Does It Mean to Process a Prescription? – Processing a prescription means taking all of the necessary steps that should be taken in order to evaluate a prescription, verify its medical importance, benefits, or side effects, enter a patient’s insurance data along with insurance plans, and properly guide the patient about the specific dosage and any possible side effects. 
What is a quantity limit?
The maximum amount of a prescription medication that can be dispensed to you at one time by your pharmacy is referred to as the quantity limit for that medication (for example, 30 tablets per month). Certain medications have maximum allowable doses in order to assist encourage responsible drug use, guarantee their efficacy, and keep costs down.
What is step therapy criteria?
Patients will benefit from better bargains and lower prescription costs as a direct result of today’s action taken by the Centers for Medicare & Medicaid Services (CMS) to inject much-needed competition and negotiation into the market for physician-administered and other Part B drugs.
The Centers for Medicare and Medicaid Services (CMS) will give Medicare Advantage plans the option of applying step therapy for physician-administered and other Part B drugs in a manner that reduces costs and improves the quality of care for Medicare beneficiaries as part of the agency’s ongoing activities to deliver on the promises made by President Trump and outlined in his American Patients First Blueprint.
These activities are part of the CMS’s efforts to fulfill the goals outlined in President Trump’s blueprint. Beginning on January 1, 2019, Medicare Advantage (MA) plans will be given the option to employ step therapy as a means of managing Part B medicines.
- This is a component of larger care coordination efforts that include involve patient rewards and incentives.
- At the moment, there are around 20 million people who are beneficiaries who are registered in MA plans.
- What exactly is this “Step Therapy”? Step therapy is a type of prior authorization for drugs that begins treatment for a medical condition with the drug therapy that is preferred the most and progresses to other therapies only if necessary, with the goal of promoting better clinical decisions.
Step therapy is also known as sequential therapy. For instance, the utilization of step therapy plans may make it possible to ensure that a senior patient who has recently been diagnosed with a condition receives initial treatment with a biosimilar medication that is both effective and inexpensive before moving on to more expensive drug therapy in the event that the initial treatment is ineffective.
There will be a reduction in expenses and an improvement in the quality of treatment for Medicare recipients if the state of Massachusetts implements step therapy in conjunction with programs for care coordination and medication adherence. The New Directional Spheres When it comes to drugs and biologicals that are administered in a doctor’s office, such as injections and infusions, traditional Medicare’s Part B generally pays clinicians a percentage that is above the average sales price.
This percentage is calculated by taking the average sales price and adding 6% to it. Due to the nature of this payment mechanism, there is minimal room for bargaining over the cost of these medications. The currently applicable CMS advice disallowed step treatment and strongly discouraged health plans from making use of prior authorization for Part B medications.
As a direct consequence of this, Medicare Advantage plans have very little capacity to bargain on behalf of beneficiaries in order to get a more favorable price for Part B medicines. Patients enrolled in MA plans, as well as taxpayers, will get a better bargain as a result of this guideline being rescinded.
These talks may also result in a reduction in the Average Sales Price for pharmaceuticals covered under Part B, which would likely result in a reduction of the copayments that beneficiaries of conventional Medicare are required to make. The Pooling of Resources The rules for step treatment under Part B may help cut expenses for the beneficiaries as well as for the MA plans.
- The awards that are given out as a part of the drug management care coordination program will be required to be passed on to the beneficiaries of MA plans, as this is a requirement of the MA plans.
- In order for the rewards to be passed on to the patient, they will need to be comparable to more than half of the average amount saved by each participant.
Availability of Drugs Under Part B All Medicare Advantage (MA) plans are still obligated to offer their members coverage for any and all Part B medications that are considered medically essential. If the beneficiary believes they require direct access to a medicine that would ordinarily only be accessible after first attempting an alternative drug, they have the option of submitting a request to the MA plan for an exemption.
- In addition, the MA plans will make certain that the new step therapy requirements do not interfere with the current pharmacological treatments that beneficiaries get under Part B.
- Step treatment can now only be applied to new prescriptions or administrations of Part B pharmaceuticals for beneficiaries who are not currently receiving the impacted medication.
This restriction was put in place in accordance with the new policy. This indicates that no recipient who is presently getting pharmaceuticals under part B will be required to make any changes to the prescription that they are taking. Step Therapy Implementation and Protective Measures for Beneficiaries Beneficiaries will be protected by a number of programmatic safeguards, and at the same time, they will be able to take advantage of the increased flexibility.
- First, during the upcoming annual Medicare Open Enrollment period, which will take place from October 15, 2018 until December 7, 2018, beneficiaries will have the opportunity to select the Medicare Advantage plan that is most suitable for them.
- This includes the option to select a plan that includes step therapy if such a plan is available in the beneficiary’s region.
In addition, enrollees in Medicare Advantage, including new enrollees in Medicare Advantage, have the opportunity to make a one-time election between January 1 and March 31 of each year to switch from their current Medicare Advantage plan to either Original Medicare or another Medicare Advantage plan.
- This election period runs from the beginning of the year until the end of the year.
- People who take advantage of this chance to make a change have the option of coordinating that change with an addition or deletion of their Part D coverage.
- In the Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents that are provided to enrollees prior to the Medicare Open Enrollment period to assist them in making plan selections for the following year, Medicare Advantage (MA) plans that participate in Part B step therapy are required to disclose that Part B drugs may be subject to step therapy requirements.
This disclosure must be made regarding the possibility that Part B drugs will be subject to step therapy requirements. In order to comply with the requirements of the drug management care coordination program, medical assistance plans that opt to offer Part B step treatment will be required to combine step therapy with newly implemented patient-centered care coordination services for beneficiaries.
Care coordination must include having a conversation with beneficiaries about the various medication options available to them, delivering educational materials and information to beneficiaries regarding their medications, and developing adherence strategies for beneficiaries who are currently following a medication regimen.
Additionally, in order to encourage beneficiaries to take part in the program for medication management and care coordination, MA plans will offer incentives in the form of awards. In addition, Medicare Advantage plans run the risk of incurring penalties if they do not spend at least 85 percent of their income on healthcare services and activities aimed at enhancing the quality of treatment.
This provision serves as a powerful incentive for plans to invest the money generated by step therapy in healthcare and other activities that are beneficial to participants. Finally, if a beneficiary is enrolled in a plan that provides step therapy, they have the ability to ask the MA plan for an expedited exception if they believe they require immediate access to a drug that would normally only be available after first attempting an alternative drug.
This is the case even if they do not believe they require immediate access to the drug. Requests for exceptions will be fulfilled in a timely manner that is commensurate with the beneficiary’s current state of health, often within a period of 72 hours.
- A beneficiary has the right to appeal if their request is denied by a plan, and CMS will be monitoring the activity of appeals to ensure that beneficiaries’ requests are adequately reviewed.
- If a plan declines a beneficiary’s request, the beneficiary has the right to appeal.
- Plans are obliged to provide subscribers with a written notice of its decisions and information on how to appeal the decision.
Plans are also required to offer enrollees with information on how to access their benefits. You may get further details on the Medicare Advantage appeals procedure by visiting the following website: https://www.medicare.gov/claims-and-appeals/file-an-appeal/medicare-health-plan/medicare-health-plan-appeals.html.
What is step therapy for Part B drugs?
As of the first of the year 2019, Medicare Advantage Plans are permitted to employ step treatment for medications that are covered by Medicare Part B. Step treatment is a utilization management strategy that enables a plan to require an enrollee to try an alternative medicine that addresses the same ailment at a lower cost before the plan would cover a more expensive prescription.