Proposed Rule Aimed at Lowering Medicare Advantage and Part D Drug Prices / by Joe Furia

Debbie Johnston, Senior Vice President of Policy Development

On November 26th the Centers for Medicare & Medicaid Services (CMS) released a proposed rule aimed at lowering drug prices for beneficiaries enrolled in Medicare Advantage (MA) and Part D programs. The proposed rule seeks to ensure that MA and Part D plans have more tools to negotiate lower drug prices for seniors enrolled in Medicare. In addition, this proposal indicates that the agency is considering a policy that would require pharmacy rebates to be passed on to seniors to lower their drug costs at the pharmacy.

The proposed rule would:

  • Provide Part D plans with the option to exclude certain drugs from current “protected” therapeutic classes, allowing plans to negotiate the price of excluded drugs, potentially translating to lower costs for seniors at the counter.

  • Require Part D plans to increase transparency and provide enrollees and their doctors with a patient’s out-of-pocket cost obligations for prescription drugs when a prescription is written.

  • Prohibit pharmacy gag clauses in Part D prescription drug plans.

  • Similar to a 2019 MA Part B step therapy policy, codify regulatory language that allows MA plans to require step therapy in an attempt to increase access to high-value products, including biosimilars.

Consider a policy for a future plan year, potentially as early as 2020, that would ensure enrollees pay the lowest cost for the prescription drugs they pick up at the pharmacy.

The Administration’s continued focus on lowering prescription drug costs is appreciated considering the threat that high and rising drug costs pose to patient access to care, especially for seniors. However, we have concerns about provisions in the proposed rule that may negatively impact patient access to care. CMS will accept comments on the rule through January 25th.