|Fall 2019 Volume 12, Number 3|
Important Changes to Medicare Part D
If you're retired and have health care coverage through Medicare Advantage Part C or Original Medicare and a Part D plan, you should know that a few changes have been made.
The Centers for Medicare & Medicaid Services (CMS) issued a final rule this year to modernize and improve the Medicare Advantage and Part D programs.
The new rules ensure that patients have greater transparency into the cost of prescription drugs in Part D and also enables Medicare Advantage plans to negotiate better prices for physician-administered medicines in Part C.
Part D Protected Classes
A drug formulary is a list of prescription drugs, both generic and brand name, that are covered under a plan. Part D policies must include these six drug classes on their formularies:
The rules also codified an existing policy specifying that Part D sponsors can only impose prior authorization and step therapy requirements for those who are starting a new drug regime for five of the six protected classes, with no prior authorization or step therapy allowed for antiretrovirals. Step therapy is a procedure where the patient is required to try a generic drug before moving to the more expensive brand name drugs.
E-Prescribing and the Part D Prescription Drug Program
An electronic Real Time Benefit Tool (RTBT) gives prescribers visibility to cost and coverage information within their electronic health record (EHR). CMS requires each Part D plan sponsor to adopt one or more RTBTs capable of integrating with at least one prescriber's electronic health record. This must be in place no later than Jan. 1, 2021.
Medicare Advantage and Step Therapy for Part B Drugs
CMS will soon finalize regulations to require step therapy for Part B drugs. Part B step therapy regulations include a number of safeguards protecting beneficiaries and ensuring timely access to "new starts" for medically necessary Part B drugs.
Part D Explanation of Benefits
Beginning in 2021, Part D Explanation of Benefits should include information about how Medicare beneficiaries can lower their out-of-pocket costs by considering a lower cost medication.
Prohibition Against Gag Clauses in Pharmacy Contracts
Part D sponsors cannot prohibit or penalize a pharmacy from disclosing a lower cash price to an enrollee.
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