CMS Allows Medicare Advantage Plans to Apply Step Therapy to Retinal Injections

August 10, 2018: By Joan McKenna

Medicare Advantage plans can require step therapy for retinal injections under new rules announced Aug. 7 by US health officials.

Step therapy calls for patients first to try lower-cost drugs before moving to a more expensive alternative if the first treatment is not effective.

The Centers for Medicare and Medicaid Services (CMS) said the change applies to physician-administered and other Part B drugs starting Jan. 1, 2019. It applies only to newly prescribed medications.

The CMS covers off-label use of cancer drug Avastin (Genentech) for wet age-related macular degeneration (AMD) and other retinal diseases, as well as the approved eye drugs Lucentis (Genentech) and Eylea (Regeneron).

Intravitreal (IVT) Avastin has a much lower per-dose cost than Lucentis or Eylea. Medicare pays $54 for IVT Avastin in 2018; $1,762 for Lucentis 0.5 mg; and $1,826 for Eylea.

Medicare pays ophthalmologists the price of the drug plus 6 percent when they purchase drugs.

Market Scope surveys from 2015 to 2017 indicated that more than 58 percent of retina specialists used IVT Avastin in 2015, and more than 50 percent used it in 2016 and 2017.

Medicare Advantage plans are private insurance plans that cover traditional Medicare services and often extra services. These plans serve 20 million Americans, a third of all Medicare patients, according to the CMS. In 2017, Medicare Advantage plans spent $11.9 billion on Medicare Part B drugs.

Market Scope estimates that 1.8 million Americans have wet AMD in 2018.

US Health Secretary Alex Azar said the goal is to “drive down prices for some of the most expensive drugs seniors use.”

Azar added that he already is looking down the road to similar tactics for Medicare.

Patients can ask their plan for an exception to step therapy if they feel a higher-priced drug is necessary; the plan must review the request expeditiously, and the CMS plans to monitor appeals.

Some private insurers have required step therapy for years.

Market Scope will cover this topic in more detail in the August 2018 issue of Ophthalmic Market Perspectives. Click here to subscribe.

Need Deeper Analysis? Sign up for Market Scope's monthly newsletter to get in-depth coverage of the ophthalmic market, including quarterly procedure volumes based on survey data and meeting coverage from around the world.

Recent Ophthalmic News

CMS Allows Medicare Advantage Plans to Apply Step Therapy to Retinal Injections

Glaukos Reports Drug Collaboration with D. Western, Q2-2018 Net Sales Increase of 5 Percent

Allergan Will Co-develop Editas’ CRISPR Genome Editing Candidate for LCA10

Spark Reports Q2-2018 Net Sales of $4.3 Million for Luxturna

Aerie’s Rhopressa Posts $2.4 Million in Net Revenues in Q2-2018

Astellas Acquires Quethera, Glaucoma Gene Therapy Candidate in Potential $109 Million Deal

STAAR Surgical Completes $77.9 Million Public Offering

Rheon’s eyeWatch Adjustable Glaucoma Device Implanted in Three UK Patients

Carl Zeiss Meditec Revenues Total $356 Million in Third Quarter of FY2018, a 12.7 Percent Increase

Kedalion Therapeutics Raises $5 Million in Series A Financing

Second Sight Reports 17 Argus II Implantations in Q2-2018; Firm to Focus on Orion System

Iridex Revenues Grow 3 Percent in Q2-2018

Omeros Revenues Drop Steeply with Omidria’s Temporary Loss of Pass-through Status

Shire’s Xiidra Delivers $100 Million in Q2-2018 Revenues, an Increase of 75 Percent

STAAR Posts Q2-2018 Revenues of $33.9 Million, a 55 Percent Increase

Avedro Names Glaukos CEO Thomas Burns to its Board

Aerie Licenses DSM’s Bioerodible Implant Technology for Ophthalmic Use for $15 Million

Alimera’s Q2-2018 Revenues Increase 5 Percent

Presbyopia Therapies’ PRX Meets Phase IIb Endpoints

Clinical Study of Imprimis’ Dropless Formulation Set to Begin in Canada

Coming soon

2018 Ophthalmic Laser Report: A Global Market Analysis for 2017 to 2023 (Photocoagulation, Photodisruption, and SLT