Life Sciences

Part D plans likely to use prior authorization following Medicare policy

Medicare & Reimbursement Advisor Weekly, April 29, 2009

Managed care readers have confirmed our report from the April 22 MRAW about how Part D plans will use a hard prior authorization (PA) instead of a step edit in response to Medicare’s new fail first/step policy. The goal of the hard PA is for these plans to control utilization of approved, branded products when they have the same indication as an off-label drug. The CMS policy involves plans participating in the program in 2010. Plans will not be allowed to require enrollees to try and fail off-label indicated drugs before providing access to an on-label drug, unless the off-label indication is supported by widely used treatment guidelines or clinical literature. The literature, according to CMS, must represent best practices. Of the eight plans (three national, five regional/local plans) we reached for comment about the likelihood of a hard PA to be used in situations when the step 1 drug (used off-label) has the same indication as the step 2 drug, four rated the likelihood of a hard PA an 8 out of 10 (on a 10-point scale in which 10 equals highly likely, and 1 equals highly unlikely). Two plans (both national) rated the likelihood a 7. One plan rated it a 10, and another plan rated the likelihood a 6.