Step Therapy/Fail First
AWIR is opposed to current utilization management tools prohibiting a patient from accessing a drug prescribed by their doctor until they fail on the preferred drug or set of drugs covered by their health plan. Preferred drugs are selected by Pharmacy Benefit Managers (PBMs) as a result of the rebate system and not based upon medical effectiveness. Many states do not have exceptions in place to bypass this process even when there is medical evidence proving the patient has already failed those drugs or they have a medical issue where it would be harmful for them to take that medication.
Each year patients are affected by formulary driven switching for non-medical reasons. AWIR believes that medically stable patients should not be switched off of their medication for non-medical reasons at any point during their plan year and that the patient should be grandfathered with year-over-year protections. Legislation supported by AWIR would prohibit a patient’s drug from being removed from the formulary or moved to a more restrictive or costly tier unless the drug was to be deemed unsafe by the FDA.
Accumulator Adjustment Programs
AWIR is opposed to “accumulator adjustment programs” which is a new utilization management tool that excludes co-pay assistance from counting towards a patient’s deductible or other out-of-pocket maximum. Under accumulator adjustment programs, patients have to pay off the full value of their deductible after the value of their co-pay assistance runs out for the year. These costs may prove unmanageable for patients on expensive specialty medications, threatening adherence to their treatment plan.
Prior authorization puts a large administrative burden on physicians. AWIR supports uniformed prior authorization legislation that: (1) requires insurers to use the uniform prior authorization form, adopted by the Department of Insurance, for prescription medications, medical treatments and procedures; (2) requires the form to be electronically accessible and able to be submitted electronically; (3) deem authorization granted if an insurer fails to respond to or accept the uniform prior authorization form within 5 business days or, for urgent requests, 1 business day upon receipt of a request.
Improving Seniors Timely Access to Care Act HR3107 — Standardizes the use of prior authorization in Medicare Advantage (MA) plans by establishing a streamlined and transparent electronic transmission process for submitting prior authorization requests.
Fair Drug Pricing & Increased Transparency
A Pharmacy Benefit Manager (PBM) is hired by health plans to manage drug programs. AWIR supports requiring PBMs to regularly report the difference between what they charge a health plan for a given drug and what it reimburses the pharmacy for dispensing it. Drug pricing has been a major issue in recent years that has continued to affect a patient’s ability to obtain their specialty medication.
To confront this issue AWIR has joined the Alliance for Transparent and Affordable Prescriptions (ATAP), which has been tasked to contest transparency in drug pricing on the state and federal level on behalf of patients and providers.
Prescription Drug for the People Act HR2376 — Tasks the FTC with studying the pharmaceutical supply chain and PBM merger activities.
Lower Health Care Costs Act S1895 (Sec. 306) — Requires PBMs to be transparent about the revenue they receive from manufacturers and ensures 100% of rebate savings will be passed onto plans.
Growth in future demand for physicians will be the highest among specialties that predominantly serve the elderly. AWIR understands the need to address this issue and is supporting legislation that promotes the development of rheumatologists in the United States.
International Pricing Index (IPI) for Part B Drugs
AWIR opposes the creation of middlemen in Part B and prefers an alternative in which physicians could remain in a buy-and-bill system. AWIR opposes requiring physicians to pay for distribution of Part B drugs, and also opposes mandatory participation in the program.
Gender Pay Gap
Female doctors are being paid less than their male counterparts. At the time of the Equal Pay Act’s (EPA) passage in 1963, women earned merely 59 cents to every dollar earned by men. Enforcement of the EPA as well as other civil rights laws have helped to narrow the wage gap, however significant disparities remain and need to be addressed. Currently, women still earn only 77 cents on average for every dollar earned by men. Improvements and modifications to existing law are necessary to ensure there are effective protections for those subject to pay discrimination on the basis of gender. AWIR supports closing loopholes in existing laws which have resulted in pay disparities for women for decades.
DXA Screening Reimbursement
Medicare beneficiaries, particularly older women, are at greater risk of fractures from osteoporosis, which can lead to disability or death. These devastating consequences can be avoided if Medicare beneficiaries have access to recommended screening. Despite the demonstrated value of screening to patients and the Medicare program, CMS has cut reimbursement significantly for DXA testing. These cuts have had serious consequences – reversing a decade of prevention efforts and leading to an increase in hip fractures. AWIR supports legislative efforts to increase access to osteoporosis screening for patients by restoring previous Medicare reimbursement rates for DXA testing.