CMS Proposed Changes to Prescription Benefits

Donna White

Donna White

By Donna White, Principal Consultant and Owner of Legacy Consulting Services and Legacy Billing Solutions in Montgomery, Alabama.

At the end of last month, CMS proposed a rule to change some key components of prescription coverage for Medicare Part D and Medicare Advantage beneficiaries.

The key change revolves around the six protected classes: antidepressants, antipsychotics, anticonvulsants, immunosuppressants for transplant rejections, antiretrovirals and antineoplastics (typically cancer treatment drugs). The six protected classes acknowledge that beneficiaries may need access to more than one drug in a particular therapeutic class.

The proposed rule offers exceptions that would allow Part D to not cover a protected class drug. The goal is to put a greater use on pre-authorizations and step therapy. Step therapy is when providers start out prescribing the most cost-effective drug therapy and progresses to costlier options if necessary. United Health Care has already had this practice in place.

The rule also excludes a protected drug from a formulary list if the drug is just a new formulation of an existing drug. It also can exclude a drug from the formulary if the price has increased beyond a certain look-back period.

Additionally, the rule proposes the addition of a real-time benefit tool to be implemented by January 1, 2020. This tool can inform providers when a lower cost drug therapy is available under a patient’s plan.

These changes will come as a win for insurers and pharmacy benefit managers (PBMs). This will allow PBMs to negotiate lower prices for Part D or Medicare Advantage plans, something they have not been able to do in the past.

The comment period for this proposed rule is through January 25, 2019. We will continue to watch these developments and provide updates as they come.

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