MHCC 25-01 Actuarial Consulting - Elimination of Step Therapy for Metastatic Cancer Side Effect Tre

The Maryland Health Care Commission (MHCC) seeks a Contractor to conduct an analysis that requires health insurers, nonprofit health service plans, and health maintenance organizations to eliminate step therapy for associated conditions and side effects of treatment for Metastatic Cancer. While Metastatic Cancer does not have any known cures, some treatments can prolong life and reduce symptoms. Many of the treatments come with side effects, including severe pain, nausea, fatigue, lymphedema, issues with white blood cell counts, and more. Often, oncologists and other physicians treat patients struggling with various drugs that control the side effects of the treatments. In some instances, health plans apply step therapy on drugs that control the side effects of metastatic cancer treatment. For health plans, the impetus for step therapy—and the integration of pharmacy benefit managers (PBMs) and treatment pathways into the care process—is to lower costs, improve quality of life, and ensure that patients receive the most preferred cost-effective therapy.  There are sometimes negative consequences as patients may have to ‘step’ through several treatments before the health plan authorizes what the treating oncologist believes is the optimal drug for controlling side effects.  The step-therapy process to treat a metastatic cancer patient often entails the patient, the patient's family, the oncology pharmacy, and the oncologist submitting documentation supporting the use of a specific agent for the patient. The removal of step therapy may help eliminate the delays, stress, and negative health outcomes for patients.

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