New Studies Underscore Doctor, Patient Burden of PA in Medicare Part B

Jul 17
Jul 17, 2025

As insurers pledge to reduce the number of medical procedures subject to prior authorization (PA), industry experts say those efforts could trickle down to prescription drugs. According to Avalere Health research, Medicare Advantage plans’ increasing reliance on step therapy (ST) for Medicare Part B-covered therapies has become particularly burdensome for patients and providers, highlighting one potential reform target. But a policy banning its use was reversed by CMS during Donald Trump’s first presidency, and an effort to undo that during the Joe Biden administration did not pan out.

In the prescription drug benefit, both PA and ST are utilization management (UM) tactics used by insurers to guide enrollees toward more cost-effective therapies. ST typically requires patients to try a lower cost alternative or a drug with preferred formulary status before moving to the therapy their physician initially prescribed.
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Lauren Flynn Kelly

Lauren has been covering health business issues since the early 2000s and specializes in in-depth reporting on Medicare Advantage, managed Medicaid and Medicare Part D. She also possesses a deep understanding of the complex world of pharmacy benefit management, having written AIS Health’s Radar on Drug Benefits from 2004 to 2005 and again from 2011 to 2016. In addition to her role as managing editor of Radar on Medicare Advantage, she oversees AIS Health’s publications and manages the health editorial staff. She graduated from Vassar College with a B.A. in English.