For Part D Drug Plans, biosimilar medications are critical to many Alliance specialties in the care and treatment of patients with autoimmune diseases managed by specialty medical physicians. Unfortunately, they are increasingly challenging to access due to step therapy requirements. To secure the needed “fail first” positioning, manufacturers have “over-rebated” these medications to the point that their average sales price (ASP), on which Part B reimbursement is based, has diminished well below the cost borne by physicians to purchase them. The Alliance urges CMS to withdraw the 2018 step therapy memorandum and allow enrollees to bypass “fail first” requirements and access an alternative therapy when the biosimilar is “underwater.”
Additionally, the Alliance urges CMS to require MA plans to:
- Follow a standardized process for all medical record requests;
- Clearly identify the nature of their medical record request (e.g., RADV, other purpose, etc.) and provide written documentation when requests are mandated as part of CMS-initiated audits;
- Provide reasonable deadlines for medical record submissions, as well as a process for extending the submission deadline for extenuating circumstances;
- Limit the number and volume of medical record requests (e.g., no more than once per year and no more than 20 records per physician);
- Allow practices to submit medical records through a secure web portal, on CD/DVD, or by fax when possible; and
- Reimburse practices for completing medical record requests at a rate no less than is set under State law.
The full letter to CMS can be accessed by clicking on the link below:
