Another reason to question going with a Medicare Advantage plan

[REWahoo]

A ruling from the Centers for Medicare and Medicaid Services (CMS) will allow Medicare Advantage plans to implement "step therapy" provisions starting in 2019....

With step therapy, patients must try cheaper medicines first before they're allowed to move to newer, costlier drugs. Critics of the policy and patient advocates often call this "fail first" therapy because the expectation is that patients must fail on certain drugs before they get access to one that may work best for them...

... seniors, those likeliest to have chronic conditions and other health concerns that require expensive drugs, may now be subject to step therapy regimens that they may be unprepared to deal with. What's more, sometimes a patient's health may deteriorate as she goes through the steps.

This drug cost-cutting strategy may harm Medicare patients

I'm sticking with traditional Medicare and a a Part D drug plan. I want to continue to have the option to choose a newer, more expensive drug if my physician recommends it as the better treatment option. Sounds like Advantage plans might take away that choice.

 

[Vacation4us]

HMO's routinely only prescribe formulary meds. I.e. Generic drugs equals cost savings. Sometimes this means less effective drugs than are currently available. Think Diabetes, Regular and NPH insulin only compared to all the new therapies.

My brother a diabetic swears a prominent HMO that starts with K was killing him, now that he has access to newer therapies his A1C is far better.

Your health is invaluable sometimes you get what you pay for. My personal opinion is an HMO is only for the young and healthy if you get sick kiss your loved ones good bye.

 

[Gotadimple]

Well, sort of another reason. Part D Plans currently require step therapy. Medicare Advantage where (most but not all) MA plans include Part D have not had the option for step therapy.

So if you have a Part D Plan now you have step therapy. If you have a MA plan, you may be subject to step therapy - but not on a retroactive basis.


Part D rules: https://www.medicare.gov/drug-coverage-part-d/what-drug-plans-cover/drug-plan-coverage-rules

Effect of the option to include step therapy in Medicare Advantage: https://www.cms.gov/newsroom/fact-s...r-authorization-and-step-therapy-part-b-drugs


- Rita

 

[Bamaman]

Advantage works like a HMO where the gov't. pays "X" dollars a month for coverage. Hospitals and physicians don't like being dictated to like they are on Medicare Advantage.

The big multi state hospital chain north of me takes regular Medicare but refuses to accept Advantage in any of the dozens of hospitals they own and manage. Their 1700 physicians and nurse practitioners in their clinics are also banned from taking Advantage. That means thousands of patients now have to go out of town to different hospitals, like HCA, and they had to get new physicians.

We had Kaiser Permanente HMO's in a couple of different cities, and they were okay for minor issues. But when the wife needed the best of care, they didn't provide it. When we switched to conventional insurance, her problem was cured in one office visit and one simple procedure. She had suffered for years.

 

[homestead]

I asked my Med. Insurance advisor about this and she said ...
"Medicare Advantage plans have already been using “Step Therapy” since the Part D program was created."
Our Advantage plan is Regence BCBS PPO. This doesn't affect us right now since we don't take drugs. So far we like the plan.

 

[MBSC]

Part D Plans currently require step therapy. Medicare Advantage where (most but not all) MA plans include Part D have not had the option for step therapy.

I asked my Med. Insurance advisor about this and she said ...
"Medicare Advantage plans have already been using “Step Therapy” since the Part D program was created.".

Part D plans embedded within MA plans already use step therapy. This expands step therapy to include Part B drugs covered under the MA plan's health benefit. Part B drugs are often used in chemo treatment.

ETA: Original Medicare does not require step therapy for Part B drugs but it may be standard protocol for certain medical providers.

CMS will provide Medicare Advantage plans the option of applying step therapy for physician-administered and other Part B drugs...

Reference: https://www.cms.gov/newsroom/fact-s...r-authorization-and-step-therapy-part-b-drugs

 

[REWahoo]

MBSC, thanks for the clarification.

How about Part B currently - does it require the step therapy that Advantage plans may now apply?

 

[MBSC]

MBSC, thanks for the clarification.

How about Part B currently - does it require the step therapy that Advantage plans may now apply?

Original Medicare does not require step therapy for Part B drugs but it may be standard protocol for certain medical providers. I edited the previous post to include this.