CMS Rule Reduces Cost-Sharing, Increases Transparency for Medicare Advantage, Part D

The Centers for Medicare & Medicaid Services (CMS) finalized a rule in an effort to improve both Medicare Advantage and Part D prescription drug programs.

Under the changes, generally in effect come 2022, the agency plans to improve coverage, increase access, and make plans more transparent to beneficiaries. The new rule would potentially lower cost-sharing for some of the most expensive prescription drugs.

“The changes in this final rule provide desperately needed transparency on the out-of-pocket costs for prescription drugs that have been obscured for seniors,” said CMS Administrator Seema Verma. “It will strengthen Part D plans’ negotiating power with prescription drug manufacturers so American patients can get a better deal.”

Starting January 1, 2023, the new rule will require Part D plans to offer a real-time benefit comparison tool so enrollees can obtain information about lower-cost alternative therapies under their prescription drug benefit plan, including the ability to compare cost-sharing.

Under Part D and the new rule, health plans will be able to create a second preferred specialty drug tier with decreased cost-sharing, compared to what exists now where all specialty tier drugs have the same level of cost-sharing. This change, the agency said, “gives Part D plans more tools to negotiate better deals with manufacturers on the highest-cost drugs and lower out-of-pocket costs for enrollees in exchange for placing these products on the preferred specialty tier.”

Additionally, under the new rule, CMS will be requiring Part D plans to disclose pharmacy performance measures directly to the agency so that the data can be shared publicly and provide opportunity for improvements.  

CMS estimates that the changes will save approximately $75.4 million for the federal government over 10 years. —Edan Stanley