Medicare Part B Step Therapy for Medicare Advantage Plans: Step Therapy for Part B Drugs

The last thing any Medicare Beneficiary who just got diagnosed with cancer wants to hear is prior authorization requests and step therapy implementation from their provider. Some people call it a “trial-and-error or death therapy” approach to your Medicare Part B prescription drug coverage.

Most if not all, Medicare Advantage plans require their members to try prescription drugs that are less expensive and potentially less effective but may have the same results before they have access to more expensive medications.

If your healthcare doctor or hospital is administering your medication this falls under your Medicare Part B coverage. Medicare Advantage plan requires you to try their less expensive drug first before they will consider your doctor’s treatment plan.

Let’s explore further step therapy and why Original Medicare with a Medigap Policy is the solution to the problem.

Table of Contents

Step Therapy Medicare Advantage Plans

What is Step Therapy for Part B Prescription Drug Coverage?

Step therapy is a process that helps Medicare Advantage plans manage their costs related to your care. It’s an important part of the program for the insurance company but not so much for the Medicare enrollee.

The steps in step therapy include identifying the problem, developing a treatment plan produced by the insurance company, and monitoring the patient’s progress.

Medicare Part B provides coverage for outpatient services, including step therapy. Plans can use step therapy savings to help patients with specific conditions or disorders, such as heart disease, cancer, tumors, or diabetes mellitus.

The goal of a step therapy program is to improve the patient’s health by correcting underlying problems and preventing future illnesses or injuries in a more cost-effective way for the insurance company.

Medicare Advantage plans will apply a 20 percent coinsurance or copay up to your max out-of-pocket cost.

Step Therapy Policy for Medicare Part B - Preferred Drugs

When people need to take a new medication, their first option may be to try it as part of their regular treatment plan—this is called “conventional” treatment. 

If this approach doesn’t work, they may have to go through a process called “step up” where their doctor increases the dose of an already prescribed medication until it works better than before (or until the patient reaches his or her maximum allowable dose).

Alternatively, some patients might need one of several “step down” medications—these medicines lower blood pressure levels gradually over time instead of abruptly stopping them as traditional antihypertensives do.

In either case, people can only receive one step of therapy drug at a time and they must wait six months after finishing their last step of the therapy medication regimen before receiving another one.

medicare advantage plan

Why do Medicare Advantage Plans Require Step Therapy for certain Conditions?

Centers for Medicare & Medicaid Services “CMS” run by the federal government issued a mandate that authorized new guidance for Medicare Advantage plans to utilize step therapy. 

This drug management care coordination program allows the insurance company use utilize a less expensive drug that treats your medicare condition.

Medicare Advantage Plans now have the approval to provide lower costs Part B medication versus prescribing what your doctor is recommending for treatment.

There are different types of step therapies that an individual may need to go through in order to be eligible for full Part B coverage. Each type of step therapy has its own set of eligibility requirements and restrictions on when it can be used.

Does Original Medicare with a Medigap Plan Require Step Therapy?

No, Original Medicare with a Medigap plan does not require step therapy.

Your treating physician maintains control of your coverage decisions related to your needed treatment plan. 

Your Medicare Supplement plan has no say in how your treatment or what Part B drugs may or may not be used. Medigap plans are not part of CMS guidelines for Part B step therapy requirements.

Once your doctor shows a treatment plan is medically necessary, Original Medicare will approve the plan and bill your Medigap plan for payment.


My Cancer Doctor Has the Best Treatment Plan: Why is the Medicare Advantage Insurance Company going Against my Doctor's Recommendation?

The Medicare Advantage insurance company may choose a different treatment plan than the doctor has recommended. CMS guidelines allow Medicare Advantage plans to implement step therapy to lower drug costs for the insurance company and the Medicare Beneficiary.

The primary reason this can happen is that the Medicare Advantage insurance company wants to save money on its budget and try a different more affordable option.

The decision of whether or not to follow a doctor’s recommendation often depends on how much money the Medicare Advantage insurance company thinks it will cost.

Sometimes, this decision can be unfair for people with cancer who have specific needs that must be met in order for their treatment to be successful. Unfortunately, health care savings is of greater value than patient care.

Are there any Drawbacks to using Step Therapy?

Step Therapy can take a lot of time to set up and manage, which could be a disadvantage for people who want to use it quickly. This fail-first approach is causing harm to the people who need the best health care benefits.

Patients are suffering and potentially dying while they wait for approval to use the recommended treatment plan of their specialist vs having to use step therapy for Part B benefits.

Now that Medicare Advantage plans may use step therapy effectively prohibits doctors from doing their job without prior approval from the insurance company. It is the patient’s responsibility to fight for the needed medical coverage while they are sick

Medicare Beneficiaries need proper representation on how to fight the system that is now working against them.

Can I make an Exception Request and Appeals a Step Therapy Requirement?

Yes, you can make exception requests and have the right to appeal the Step Therapy requirement imposed by your health insurance company. However, plans may require long negations between your doctor and the insurance company.

As your doctor appeals to the decision your medical condition may get worse only adding to your pain and discomfort.

In today’s environment, it is critical for them to have thorough documentation to better argue their case on why their Doctors treatment plan is required.

Medicare Part B Drug

Medicare Advantage Step Therapy Drugs

Common drugs that are included in Step Therapy?

There are many drugs that are included in Step Therapy for Medicare Advantage Plans. Some of the most common drugs are:

  1. Cholesterol-lowering Statins such as Lipitor, Zocor, and Crestor
  2. Blood pressure medications such as Diovan, Benicar, and Cozaar
  3. Anti-depressants such as Cymbalta, Effexor, Paxil, and Zoloft
  4. Anti-anxiety medications such as Ativan, Klonopin, and Xanax
  5. Narcotic pain medications such as Oxycontin, Percocet, and Vicodin

Common Cancer-fighting drugs included in Step Therapy?

There are many cancer-fighting drugs, also called “cytotoxic chemotherapy agents,” that are included in Step Therapy for Medicare Advantage Plans.

Some of the more common ones are outlined below:

  1. 5-Fluorouracil (5-FU)
  2. Capecitabine (Xeloda)
  3. Cytarabine (Ara-C)
  4. Doxorubicin (Adriamycin)
  5. Epirubicin (Ellence)
  6. Gemcitabine (Gemzar)
  7. Irinotecan (Camptosar)
  8. Oxaliplatin (Eloxatin)
  9. Paclitaxel (Abraxane, Taxol)
  10. Docetaxel (Taxotere)

Original Medicare with a Medicare Supplement Plan

Original Medicare is a type of health insurance coverage that is administered by the federal government. It is available to people who are 65 years of age or older, as well as to those who are under 65 and have certain disabilities.

Medicare Supplement Plans are private health insurance plans that help fill in the gaps in Original Medicare coverage. These plans must be approved by Medicare in order to be sold, and they are offered by a variety of different insurance companies.

Medicare Beneficiaries who do not want to participate in the utilization of step therapy are recommended to sign up for a Medigap plan and remain on traditional Medicare. 

While the costs may include a monthly premium, how much is your life worth in the hands of an insurance company looking to save a buck or two?

Request Help from a Medicare Insurance Professional

If you need help understanding your Medicare insurance options, you can reach out to one of our Medicare insurance professionals

Our insurance agents can help you understand your coverage options and find a plan that won’t require step therapy.

Integrity Now Insurance Brokers is here to provide you with honest answers related to your healthcare program. Reach out to one of our licensed insurance agents today for help signing up for a new Medicare plan and to answer questions you may have.