American Academy Ophthalmology

Last year, the Academy led a coalition of more than 60 physician & patient groups to pressure the federal government’s health watchdog, the HHS Office of Inspector General, to investigate step therapy in Medicare Advantage plans.

Today, the Academy’s seasoned advocacy team – Michael X. Repka, MD, MBA, medical director for Governmental Affairs, John McAllister, MD, secretary for Federal Affairs, and George Williams, MD, senior secretary for Advocacy – is meeting with the Office of Inspector General (OIG) as it sets out to evaluate whether Medicare Advantage plans are using step therapy tools appropriately.

Step therapy, sometimes called “fail first,” means an insurance plan makes patients try the plan’s preferred drug, and sometimes two or three of them, before it will cover the drug their doctor prescribed. Medicare banned this for doctor-administered drugs (like eye injections) until 2019, when the rules changed to allow it. Since then, its use has grown sharply: 84% of surveyed doctors report seeing more of it, and 94% say it keeps them from prescribing what’s best for their patients.

Today, our advocacy team is telling the OIG what step therapy looks like in practice. They’ll tell the story of the Tennessee patient who was blinded by step therapy. They’ll tell them plans are forcing patients who are already doing well on a drug to switch, requiring drugs that aren’t approved for the condition being treated, and pushing medications favored for financial reasons rather than medical ones. The consequences can be permanent: people with cancer or vision-threatening eye conditions losing critical time.

It’s Important to Know:

✅ The OIG makes recommendations; it’s up to the Centers for Medicare & Medicaid Services (CMS) or Congress to act to implement any policy changes.

✅ The OIG’s objective is to evaluate whether Medicare Advantage plans are using step therapy appropriately, not whether it should exist at all.

How You Can Help:

✅ Share with the Academy stories of patient harm from overutilizing of step therapy or prior authorization. Link in bio

✅ When the Academy puts out the call to contact Congress, heed it.