Rep. Onder Leads Letter Calling for Greater Transparency in Medicare Advantage

FOR IMMEDIATE RELEASE

June 4th, 2026

Contact: Brooke Morgan

(Washington, D.C.) - Today, U.S. Congressman Bob Onder (R-MO) released the following statement after leading a letter from certain members of the Doctors Caucus to the Centers for Medicare & Medicaid Services (CMS) encouraging the agency to protect Medicare Advantage beneficiaries who are being blocked from lifesaving physician-administered treatments. The letter urges CMS to establish minimum national standards for drug coverage in Medicare Advantage to address restrictive "step therapy" policies that require seniors to try insurer-preferred drugs, even when there is no access to the drug in their region.

"One of the most concerning trends in Medicare Advantage is the growing use of step therapy requirements. In traditional Medicare, physicians can quickly pivot to an alternative treatment if a drug is unavailable, but many plans force patients to try their preferred drug first - even if the drug is unavailable where they live. As members of the Doctors Caucus, we regularly hear about this from patients and physicians, and many of us have witnessed firsthand how patients are harmed when insurers restrict access to life-saving treatments," said Congressman Bob Onder, M.D.

"Our country should be moving toward a health care system that puts patients, not profits, first. Seniors who have paid into Medicare their entire lives deserve reasonable access to the treatments they need."

"Americans deserve reliable access to the treatments their doctors know work best. Washington bureaucrats and insurance companies shouldn't force seniors through unnecessary hurdles or disrupt care to cut costs. We must protect patient choice, support physicians, and ensure Medicare beneficiaries can get the care they need when they need it," said Rep. Brian Babin, D.D.S.

"As a physician, I believe treatment decisions should be made by doctors-not insurance companies. Physicians use their training, clinical experience, and knowledge of a patient's medical history to determine the best course of treatment. Yet Medicare Advantage plans often require patients to try an insurer-selected therapy before they can receive the medication prescribed by their doctor. CMS should put an end to these unnecessary insurance hurdles and allow physicians to exercise their medical judgment," said Congressman Andy Harris, M.D.

"As a physician, I know all too well the unnecessary barriers that step therapy puts between a patient and the care they need. Right now, the structure of certain Medicare Advantage plans is forcing seniors onto failed alternative drugs while squeezing local clinics so hard they can't even afford to provide the actual treatments patients need. This is a preventable bureaucratic failure, and CMS should step in and protect patient access to the care they need," said Congressman Mike Kennedy, M.D.

"To improve patient outcomes, we must ensure efficient and effective care is readily available. Oftentimes, "fail-first" practices are harmful to patients and ultimately more costly on the American taxpayer. I am proud to join my physician colleagues in addressing this shortcoming with CMS," said Rep. Neal Dunn, M.D.

"We thank Rep. Bob Onder (R-MO) and his colleagues for bringing attention to a growing problem that threatens patient access to physician-administered biosimilar medications," said Madelaine Feldman, M.D., FACR, Vice President of Advocacy & Government Affairs for the Coalition of State Rheumatology Organizations (CSRO), a Co-Chair organization of the Underwater Biosimilars Coalition."Over-rebating has created a growing number of 'underwater' biosimilars, where Medicare reimbursement falls below provider acquisition cost. At the same time, Medicare Advantage plans continue to impose step therapy requirements for these products without regard for whether physicians can afford to administer them. Biosimilars should be a cost-effective option that expands patient access and lowers healthcare spending, but the current system risks limiting access, forcing care into potentially higher-cost settings. A formulary adequacy standard would help end 'ghost formularies' and ensure that Medicare Advantage plans cannot require beneficiaries to 'fail first' a preferred biosimilar that is effectively unavailable."

To read the full letter, click here: Letter.

Background Information

Under the Medicare Advantage (MA) program, the federal government pays private insurance companies a fixed amount to provide beneficiaries with Medicare-covered services. By law, Medicare Advantage plans must cover at least the same services available under traditional Medicare. Despite these requirements, physicians and patients continue to report significant barriers to accessing medically necessary treatments, particularly physician-administered Part B drugs such as biologics and biosimilars used to treat chronic conditions including rheumatoid arthritis and inflammatory bowel disease. Providers have raised concerns that step therapy requirements and restrictive formulary policies in some Medicare Advantage plans can delay or limit access to these therapies, even when they would otherwise be covered under traditional Medicare.

Physicians are increasingly being reimbursed at rates below the amount they must pay to acquire certain Part B medications, creating financial challenges that can make it difficult to continue offering these treatments. According to a 2025 survey of nearly 200 physicians, reimbursement rates for some commonly prescribed biosimilars frequently fell below acquisition costs. Physicians reported that the actual purchase price for Inflectra exceeded reimbursement rates by 30 to 260 percent, while the purchase price for Avsola exceeded reimbursement by approximately 30 to 80 percent below acquisition cost. Rheumatologists and gastroenterologists have identified these drugs among the most common examples of medications for which providers are operating at a loss.

In traditional Medicare, physicians may be able to prescribe alternative therapies when reimbursement rates make certain drugs unavailable. However, providers report that Medicare Advantage step therapy requirements can limit those options, leaving some patients without timely access to treatment in their communities.

My colleagues and I are asking the Centers for Medicare & Medicaid Services (CMS) to improve transparency and establish safeguards that ensure Medicare Advantage plans maintain adequate formularies and provide beneficiaries with meaningful access to medically necessary Part B medications.

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