Relaxing Prior Approvals & Step Therapies for Medicare Advantage & Part D

April 2020 - This week the Centers for Medicare & Medicaid Services (CMS) issued guidance to address flexibilities available related to utilization management and prior authorization during the COVID-19 public health emergency. This revised guidance was in response to a letter that called on CMS to encourage Medicare Advantage and Part D plans to relax prior authorization and step therapy standards for medically necessary prescribed or ordered treatments and services during national pandemics. The letter was drafted by the American Academy of Dermatology (AAD) and cosigned by a number of medical colleges/associations and patient advocacy organizations, including the Cutaneous Lymphoma Foundation.

CMS is now adopting a temporary policy of relaxed enforcement in connection with, but not limited to, the following: 

  • Waiving Part D medication delivery documentation and signature log requirements
  • Relaxing to the greatest extent possible prior authorization requirements for both services and prescribed treatments, where appropriate; and/or
  • Suspending plan-coordinated pharmacy audits
  • Part D sponsors must permit enrollees to obtain the total days’ supply prescribed for a covered Part D drug up to a 90-day supply in one fill (or one refill) if:
  • Requested by the enrollee, 
  • PA or ST requirements have been satisfied; and 
  • No safety edits otherwise limit the quantity or days’ supply. 

CMS is encouraging Medicare Advantage Organizations and Part D sponsors to use these flexibilities.

Sign On Letter 

Updated Guidance for MA and Part D Plan Sponsors

FAQs for Issuer