RhAPPcast: From Prescription to Possession: Understanding Medicare Access & Cap and Smooth

In this episode of RhAPPcast, the official podcast of the Rheumatology Advanced Practice Providers, host Amanda Mixon, PA-C, is joined by rheumatology experts Heather Finlayson, PA-C, and Stacey Johnson, NP, to discuss one of the most challenging aspects of rheumatology care: ensuring patient access to advanced therapies. This conversation explores the complexities of Medicare formularies, prior authorizations, step edits, tier placement, and evolving affordability programs that support patients receiving specialty medications.Listeners will gain practical insights into how Medicare Part B and Part D coverage impacts rheumatology prescribing, including formulary restrictions, preferred therapies, and the financial barriers patients often face when accessing biologics and biosimilars. The discussion also highlights programs such as the Medicare Prescription Payment Plan (M3P), CAP, and cost-smoothing initiatives that help reduce out-of-pocket costs and improve treatment access for Medicare beneficiaries.The panel also shares practical strategies for navigating access challenges through patient education, strong documentation, communication with clinic teams and biologics coordinators, and proactive advocacy to help patients stay on therapy.Ideal for rheumatology providers, advanced practice providers, pharmacists, and clinic teams, this episode delivers actionable guidance to improve patient access, reduce treatment delays, and support long-term medication adherence in rheumatology practice.For more expert-led rheumatology education, visit the RhAPP Content Rheum and RhAPP ACE app, and subscribe to RhAPPcast for future episodes.