WASHINGTON, D.C. – The American Cancer Society Cancer Action Network (ACS CAN) released two reports today, Step Therapy in Medicare Part D Oncology Drugs and Utilization Management in Breast Cancer and Hepatocellular Carcinoma, which provide a snapshot of utilization management requirements for specific cancer drugs in both the Medicare Part D plans and Medicare Advantage plans with drug coverage. The analysis for the reports was conducted for ACS CAN by the consulting firm Avalere, part of Avalere Health.
Recent changes in the Medicare program could place pressure on private plans in Medicare to implement strategies aimed at controlling drug expenditures and optimizing utilization. However, the negative impact utilization management tools have on treatment outcomes is clear, which is why it’s critical to understand how frequently Medicare Advantage and Medicare Part D plans use these tactics.
Step Therapy in Medicare Part D Oncology Drugs looks at the extent to which Medicare Part D plans require prior authorization or step therapy for select oral oncology drugs for certain breast cancer therapies (cyclin-depended kinase 4 and 6.) While these plans require all oncology drugs to be covered, this analysis finds there are ways in which step therapy requirements can be embedded into plans disguised as prior authorization, putting patients at risk.
Utilization Management in Breast Cancer and Hepatocellular Carcinoma investigates the extent to which Medicare Advantage plans require prior authorization or step therapy on certain drugs approved to treat hepatocellular carcinoma and breast cancer. The report found most of the breast cancer drugs analyzed required step therapy in Medicare Advantage plans and most plans increased their step therapy from 2023-2024. One encouraging finding was that biosimilar drugs analyzed were more likely to have preferred status, meaning patients would not be required to “fail first” at a drug that may not be an effective option for them. Overall, the report highlights the importance of plans balancing increasing costs of care with maintaining appropriate and efficient access to medications.
Given an individual’s cancer risk increases with age, Medicare plays a key role in reducing suffering and death from cancer and should protect patients’ access to the treatments they need, not erect barriers to them. In 2024, more than 2 million individuals living in the U.S. are projected to be diagnosed with cancer, half of whom rely on the Medicare program as their primary source of health care coverage.