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Retina

Step therapy, prior authorization poses implementation issues for retinal practices

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Prior authorization and step therapy can create barriers to patient care and may be difficult for retinal practices to implement, according to a presentation at 2020 AAO Virtual.

George A Williams, MD told attendees that a recent survey by the AMA found the more than 90% of doctors think “prior authorization delays access to care and is associated with adverse clinical outcomes.”

The main focus of step therapy in retina care involves the benefit of off-label, compounded bevacizumab (Avastin). Dr Williams said that many studies show the benefit of bevacizumab, and according to 2013-2016 data from the IRIS Registry of the 6.2 million intravitreal injections performed, 46% used bevacizumab.

“The simple truth is that without the many dedicated ophthalmologists who fought for access to and payment for bevacizumab and participated in clinical trials, there would be no alternative to aflibercept and ranibizumab,” Dr Williams said.

Issues with step therapy and prior authorization by Medicare Advantage Organizations and commercial payers that Dr Williams highlighted include:

  • What criteria are used to determine treatment failure with bevacizumab, and how many injections are needed to establish failure
  • What about patients who are unwilling to receive bevacizumab?
  • Is step therapy needed when that bevacizumab is not the treatment of choice?
  • Is repeat step therapy needed for the second eye?
  • A lack of standardization of the step therapy protocols may create difficulties
  • Is an appeals process established if the ophthalmologist disagrees on treatment failure?
  • How does changing plans during a multi-year treatment program impact treatment?

Reference
Williams GA, et al. The Business of Retina – Pitfalls of Preauthorization and Step Therapy. Presented at: 2020 AAO Virtual.

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