Physician Choice of Medication
The American Society of Retina Specialists (ASRS) is concerned that several third-party payers in various locations around the U.S. have established policies to limit and restrict the use of medications to treat macular degeneration.
The ASRS believes it is inappropriate for any insurer to require the use of tiered therapy, whereby a single anti-VEGF agent (typically bevacizumab, AVASTIN) is required to be used before the use of the 2 available and FDA-approved agents (ranibizumab, LUCENTIS or aflibercept, EYLEA) are considered. Currently, of the 3 utilized anti-VEGF agents, only LUCENTIS and EYLEA have specific FDA approval, while AVASTIN does not, and is used in an “off-label” compounded manner.
In September 2012, CMS reminded Medicare Advantage Organizations that “the imposition of additional requirements for access to certain Part B drugs or services, such as step therapy requirements, is not permitted unless also required through Original Medicare.” Because Medicare does not have a step therapy requirement for anti-VEGFs, Medicare Advantage Plans cannot establish their own policy.
ASRS strongly urges insurers to continue to allow retina specialists and their patients to make wise and judicious choices based on the patient’s unique risk factors, clinical appearance, availability of compounded drugs, and economic requirements. Artificially-imposed practice modifications for non-medical, financial reasons is ill-advised and will continue to be actively opposed by the ASRS on a national and international level, and by other societies and individuals on a state and local level.
Sample letters to third-party payers
Requiring off-label use of Avastin before FDA-approved agents
ASRS letters opposing higher standards for the use of FDA-approved drugs for specific indications (ie, Eylea, Lucentis, and Macugen) than for “off-label” compounded Avastin.
- Humana, Louisville, Kentucky (Follow up letter)
- Humana, Louisville, Kentucky
- Blue Care Network, Southfield, Michigan
- Avesis, Phoenix, Arizona
- Wellmark Blue Cross and Blue Shield, Des Moines, Iowa
- Read the Executive Committee’s third-party payer letter.
CMS Response to ASRS Advocacy
Medicare Drug & Health Plan Contract Administration Group – June 16, 2014
Eylea dosing restrictions
ASRS sent a letter to Priority Health, Grand Rapids, Michigan, opposing its policy to restrict the dosing regimen of Eylea to once every 8 weeks after the first 12 weeks.
Denied payments for Lucentis
In what is possibly the most egregious example of third-party payer misconduct, ASRS sent letters to CVS/Caremark and SilverScript, opposing a new policy requiring replacing Lucentis with interferon.
Updates
ASRS Continues Urging Humana to Reverse Its Step Therapy Policy - February 4, 2015
Buyer Beware: Humana's Step Therapy Policy Blocks Patient Access to FDA-Approved Drugs - December 23, 2014
Aetna National Medical Director Supports Physician Choice and Agrees to Fix Drug Underpayments - November 10, 2014
ASRS Urges CMS to Enforce Medicare Advantage Programs With Step Therapy Policies - May 21, 2014
ASRS Continues Efforts to Ensure Retina Specialists' Choice of Medication – March 5, 2014
ASRS Opposes Tiered Therapy Policies – February 19, 2014
ASRS Physician Choice of Medication Campaign: Assistance Needed – August 13, 2013
Read the third-party payer letter from the ASRS Executive Committee. – March 22, 2013
Report an event
Please contact Jill Blim if you have any evidence that an insurance plan has a step therapy policy or is restricting beneficiaries’ access to Part B drugs or services.