Drugs

Photo from Tanja Obradovic/LinkedIn

Jun 13, 2024, 13:21

Tanja Obradovic: How prevalent are policies that mandate step therapy for cancer drugs in the US?

Tanja Obradovic shared on LinkedIn:

“How prevalent are health plan policies that mandate step therapy (particular order of treatments) for cancer drugs in the US? Just published paper released by the American Cancer Society Cancer Action Network (ACSCAN) is very informative.

Utilization management (UM) tactics are frequently used in Medicare Part D, by both Medicare Advantage-Prescription Drug plans (MA-PDs) and standalone Prescription Drug Plans (PDPs), to control prescription drug spending.

While UM is used to lower plan spending and premiums for beneficiaries, it can also make it more difficult for patients to access the prescriptions they need, especially high-cost oncology drugs.

To better understand how UM is used in Medicare, the ACSCAN looked into the extent to which step therapy restrictions exist for certain drugs that treat breast cancer, cyclin-dependent kinase 4 and 6 (CDK 4/6) inhibitors.

As usual “devil is in the details”. .

While no plans explicitly require step therapy in the formulary design, evaluation of the detailed restrictions policies to understand whether step requirements were embedded within prior authorization requirements for all Part D plans revealed that many plans included step therapy embedded within their prior authorization criteria, with step edits dependent on patient characteristics or treatment choice.

For example for Verzenio, step therapy requirements were included 82% of the time.

Interesting to note is that previous look into Medicare Advantage plans found required step therapy for breast cancer drugs 70% to 95% of the time, except for biosimilar drugs Kanjinti and Trazimera.

Although level of step therapy for cancer medication is often justified by safety concerns, there is different approach by larger and smaller health plans that does not seem to justify basis for this general assumption. At the same time concerns by practitioners are raised abut restrictive policies causing unnecessary delays in treatment subjecting patients to negative health outcomes.

Considering increased number of newly approved cancer therapies means that detailed formulary review process from CMS for coverage, tiering and utilization management will be increasingly important for Medicare cancer patients.”

Source: Tanja Obradovic/LinkedIn