Medicare Advantage & Part D Drug Price Rule

With the rising costs of medical care and prescription drugs, controlling the costs is now more critical than ever. The Centers for Medicare and Medicaid Services (CMS) finally put the new Medicare Advantage and Part D Prescription Drug Price Rule in place. The efforts were put in place to increase transparency for the price, and cost-sharing is passed on to patients.

In this bid to restructure Medicare’s prescription drug benefit, there will be many benefits that include:

Drug Formulary Changes – Every year, Medicare Part D plans can change the list of prescription medications they will cover, known as the plan formulary. The current policy includes all six categories of drug formularies, and Part D sponsors are not allowed to 1.) Exclude a protected drug class if the price increased beyond the specified look-back period, or 2.) exclude a protected drug if it is a new formulation of an existing single-source drug or biological product even if the older version is still on the market.
That means even if you are taking the same medications, the amount you pay for your prescriptions, the plans’ premiums, deductibles, and co-pays may change in 2020!

Step Therapy Part B Drug Requirement Changes for Medicare Advantage – Step therapy management will enable Medicare Advantage and Medicare beneficiaries to pay less for Part B drugs. It will also ensure access to medical necessity Part B drugs in a timelier manner. Step therapy may only apply to new starts to medication, need to be approved by the plans therapeutic and pharmacy committee. The decision-making will be shorter when an appeal of a denial is made to coincide and mimic Part D rules.

Real-time Benefit Tools with E-Prescribing – Each Part D will adopt one or more Real-Time Benefit Tools (RTBT) that can work with a minimum of one ePrescribing system or electronic health record (HER). This should be in effect by January 1, 2021. The benefit of the RTBT is that it can inform beneficiaries of lower-costs available in the prescription drug benefit plan. This helps minimize out-of-pocket expenses and can improve medication adherence.

Gag Clause Ban Changes – This rule will actually ban “gag clauses.” The benefit is now pharmacy-benefit-managers cannot prohibit pharmacists from informing patients of cost savings when using cash instead of insurance. Pharmacists will now be able to advise patients the best cost associated with prescriptions and give them a clear choice and better access to a variety of options.

Out-of-pocket Prescription Drug Costs – Part D Payment Modernization – The incentive plan is to negotiate lower drug costs for patients that hit or meet the catastrophic phase of drug coverage by putting an out-of-pocket cap and overall lowering the drug prices. With the new rule, there will be a target limit that the plan will implement. If the plan stays under that limit, the cost-saving will be passed onto the plan. If the plan goes over the target, they are responsible for the loss. The plan is at risk, but, with the additional Part D rewards and incentives and tools to control drug costs, it will help the beneficiary choose prescription drugs at lower prices overall, and the cost-sharing will have a trickling effect.

Medicare Advantage Value-Based Insurance Design (VBID) – While this concept was first launched in 2017, it will test new service delivery approaches in 2020. The goal is to allow plans to provide better-targeted cost-sharing and benefits based on customization with chronic conditions or socioeconomic status with incentive programs and reward systems. These incentive programs will help improve access to telehealth services and utilize virtual services that can replace some in-person visits.

All Medicare Advantage plans in the USA can apply in 2020 for VBID. Special Needs Plans and Regional PPOs are now available. In 20121 the VBID will allow MA plans to offer Medicare hospice benefits.

The price rule was put into effect to make sure patients have easier access, more affordable health care, and drug coverage and to allow Medicare Advantage plans to negotiate better prices for medications prescribed through physicians.

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