Medicare Compliance & Reimbursement

Strong step therapy program puts PDPs on payment path.

Not everyone thinks the Centers for Medicare and Medicaid Services' new guidance on the Part D drug benefit is cause for alarm.

One leading health care expert feels that potential PDP sponsors will be OK if they've got a top-notch step therapy plan in place.

"The reaction to this is completely overblown," says Dan Mendelson, president of Avalere Health (formerly The Health Strategies Consultancy) in Washington. PDP sponsors will still be able to use step therapy, tiered formularies and other tried-and-true tools of the pharmacy benefit management trade, Mendelson explains.

Because step therapy allows the sponsor to start the bene on a cheaper, established medication before switching him to a newer, costlier drug if necessary, it has the same result as having a restricted formulary, Mendelson says.

"They've taken away one tool but left three or four others," Mendelson says of CMS. Any sponsor with a strong step therapy program should be fine, he says.