The Centers for Medicare & Medicaid Services (CMS) is proposing to build on a 2024 interoperability rule for non-drug services by extending electronic prior authorization requirements to drugs across Medicare Advantage, Medicaid, CHIP and marketplace plans.
In response, ASGE, alongside other GI organizations, delivered comments asking that CMS finalize and strengthen the rule, including by ensuring that dose escalation requests be supported through electronic prior authorization.
Under the proposed rule, health plans would need to make publicly available approval and denial data for drug authorization requests. Those requirements are currently in place for non-drug services, but the data is aggregated. ASGE and other organizations have urged CMS to require the data to be broken down by item and service.
CMS’ proposed rule also includes a request for information on whether increased interoperability of information technology systems across payers could be used to make utilization management policies, such as step therapy, more transparent. In the comment letter, the GI organizations asked for standardization in the step-therapy exceptions process across payers, and noted that because a biologic treatment for inflammatory bowel disease, for example, may begin as IV induction under an insurer’s medical benefit and later transition to subcutaneous maintenance as a pharmacy benefit, step-therapy determinations must be transferable not only across payers, but also across benefit categories to ensure continuity of care, especially when patients switch insurance.
The comment period is now closed. The next step in the process is issuance of a final rule by CMS.