Final Rule Issued on Medicare Advantage and Medicare Part D Programs

The Trump Administration recently finalized improvements to Medicare Advantage and Medicare Part D, which provide seniors with medical and prescription drug coverage through competing private insurance plans. These changes will ensure patients have greater transparency into the cost of prescription drugs and can compare options and demand value from pharmaceutical companies.

After an implementation period, Part D plans will be required to provide access to a tool that is integrated into clinicians’ electronic prescribing or electronic health records (EHR) systems. Some plans already are offering these tools, but the new policy will require all plans to provide clinicians with access to price information for different prescription drugs.

To further promote transparency, after the implementation period, the new rule will  require the explanation of benefits document that Part D enrollees receive each month to include information on drug price increases and lower-cost therapeutic alternatives. As a result of these changes, patients and their clinicians will be able to better understand the cost of prescription drugs and seek out high-value options, helping to increase patient adherence and improving health outcomes.

The Centers for Medicare & Medicaid Services (CMS) also is codifying a policy that enables beneficiaries to select a Medicare Advantage plan that negotiates prices for physician-administered medicines when beneficiaries are first starting on the medicines. By strengthening a plan’s ability to negotiate with prescription drug companies, this policy will ensure plans can better deliver value for a patient’s medical needs.

In addition, the rule prohibits “gag clauses,” which keep pharmacists from telling patients about lower-cost ways to obtain prescription drugs. These efforts to promote transparency on the price of prescription drugs complement a series of other changes towards this important goal, including a final rule issued by CMS to require pharmaceutical companies to disclose the list price of prescription drugs in direct-to-consumer television advertisements.

In addition, CMS is considering a policy to ensure beneficiaries pay the lowest cost for the prescription drugs they pick up at a pharmacy, after taking into account back-end payments from pharmacies to plans.

For a fact sheet on the final rule, click here.

The final rule (CMS-4180-F) can be downloaded from the Federal Register here.

For more information, contact Amanda Newell at THA, 615-401-7441.