Dr Crescent Moore on the Effect of Step Therapy in MA Plans, Other Formulary Regulations

April 13, 2019

CMS has given plan sponsors the flexibility to choose which drug therapy categories they’d like to administer the Part B step on, explained Crescent Moore, PharmD, PhD, BCPS, senior consultant, BluePeak Advisors,

CMS has given plan sponsors the flexibility to choose which drug therapy categories they’d like to administer the Part B step on, explained Crescent Moore, PharmD, PhD, BCPS, senior consultant, BluePeak Advisors,

Transcript

CMS is proposing allowing step therapy in Medicare Advantage plans for Part B drugs. Which drugs will this impact, and how will patients be affected?

The beauty of it all is that CMS really has given plan sponsors flexibility to choose which drug therapy categories they’d like to administer the Part B step on, and ideally, when you start thinking about good candidates to be a part of a step therapy, you want to look at drug therapy categories that have quite a few agents in them that have similar efficacy to really help you to be able to decide where can you really kick this off. I think the other thing to take into consideration is that plans are still going to be held by those local coverage determinations and national coverage determinations, so they do need to keep that in mind.

But, if I have to use my crystal ball and think about what might be a good therapeutic category, obviously the biosimilars and those classes that have those. So, thinking about the erythropoietin agents, as well as the infliximab products. And then another one might be even the hyaluronic acid agents because of the fact that there are just so many in that class, and really from a clinical perspective, they have very similar effectiveness.

Do you think the different formulary regulations proposed by CMS will help lower drug costs?

My ideal answer, I would love to see it help lower drug costs. I think that there are still some unknowns in terms of the safe harbor rule that was recently released and what is that going to do for the industry in respect to rebates and how those dollars get redistributed. I think the other thing that we are going to have to realize is that no one is mandated to do an indication-based formulary or to do a Part B step. So, if we don’t have widespread uptake by plan sponsors of these programs, I think that the benefit that we’d like to see might not be as large as we’d hope.