Plans will have more power to make patients try cheaper
alternatives of some drugs first.
Officials at the Centers for Medicare and
Medicaid Services (CMS) have completed work on Medicare drug coverage
regulations that could give the plans help with holding down drug prices.
CMS — an arm of the U.S. Department of
Health and Human Services — will apply the new regulations
to Medicare Part D drug plans, and to Medicare Advantage plan drug
benefits.
Some provisions in the final regulations are
supposed to give consumers more information about what drugs cost and affect
how drug manufacturer rebates work.
For producers in the Medicare plan market, the
provisions that may lead to the most conversations with clients might be the
formulary cost management provisions.
A formulary is a list of the drugs a plan will
cover.
In the past, CMS has required a Medicare drug
plan formulary, or covered drug list, to include most of the available drugs in
six major drug categories: antidepressants, antipsychotics, anticonvulsants,
antiretrovirals, anticancer drugs, and immune system suppression drugs for
transplant patients.
Now, a plan can restrict access to drugs in
those categories in some cases, by, for example, letting a drug plan require
many patients to try a cheaper drug before moving up to a more expensive drug.
Requiring a patient to try a cheaper drug first is called “step therapy.”
In the commercial plan market, patients and
providers have often resisted step therapy requirements.
To ease patient concerns about the new step
therapy rules, CMS says it will speed up its process for handling patient
appeals related to the kinds of drugs affected by the new rules.
Resources
A preliminary version of the final Medicare
Part D and Medicare Advantage drug price regulations is available here.
Allison Bell, ThinkAdvisor's insurance editor, previously was
LifeHealthPro's health insurance editor. She has a bachelor's degree in
economics from Washington University in St. Louis and a master's degree in
journalism from the Medill School of Journalism at Northwestern University. She
can be reached at abell@alm.com or on Twitter at @Think_Allison.
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