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CMS seeks Part D, Advantage changes to save $1.3B, curb abuses


By Virgil Dickson
Posted: January 7, 2014 - 9:30 pm ET
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In an effort to save $1.3 billion over five years and curb the abuse of prescription drugs that Medicare pays for, the CMS is proposing an array of changes to Medicare's Part D and Advantage programs.

The suggestions range from cutting the number of plans to ensure more meaningful plan choices, ending coverage for drugs for certain illnesses, and changing the way in which pharmacies bid to be included in plans.

The CMS is suggesting that each payer offer no more than two Part D plans in the same service area, saying the limit would give consumers “meaningful differences” in coverage options. The proposed rule would also prohibit Advantage plans from offering coverage options that replace plans the CMS previously required the carrier to terminate or consolidate due to low enrollment.

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Stacy Sanders, federal policy director at the Medicare Rights Center, said the advocacy organization has received calls from people choosing from as many as 18 to 20 plans that were largely indistinguishable. “Often what happens is that people will then choose a plan solely on the premium,” Sanders said.

As a result, she said, many consumers end up enrolling in a plan that doesn't cover their specific medications or preferred pharmacy.

The rule also sets a higher standard for covering “all or substantially all” drug offerings for a specific disease group. These so-called “protected class” drugs include antineoplastics, anticonvulsants, antiretrovirals, antipsychotics, antidepressants and immunosuppressants.

The proposal would limit such coverage to drugs prescribed if the person would be hospitalized, severely incapacitated or die if they don't get the drug within seven days. With that standard in mind, the CMS would no longer require all drugs from the antidepressant and immunosuppressant drug classes to be covered. The CMS is also considering taking away the status from antipsychotics pending further study.

Winnowing the field of protected-class drugs, the CMS said, would save the Part D program $720 million between 2015 and 2019.

The CMS can expect a fight from patient advocacy groups who consider getting a class of drugs certified for such coverage “a hard-won battle,” said Dan Mendelson, CEO of Avalere Health. “It's likely they won't want to see that status go away without a fight.”

Pharmacies are especially pleased by a suggestion that would stop mail-order pharmacies from charging lower copayments than retail pharmacies. Specifically, the CMS is suggesting that one-month supplies filled by mail-order pharmacies cannot have cost-sharing lower than a comparable one-month supply filled at retail outlets.

The National Community Pharmacists Association “strongly supported” the suggestion and said data suggests that community pharmacies do a better job promoting the proper use of cost-saving generic drugs compared to mail-order companies.

In addition to saving money, the rule is also looking to curb prescription drug abuse. The CMS is proposing to exclude providers from Medicare if the government determines a pattern of abusive prescribing of Part D drugs. The agency also wants to prohibit doctors who aren't enrolled in Medicare from prescribing drugs that are reimbursed by Part D. The rule would put the onus on payers to ensure that a prescriber has the authority to prescribe under the program.

The CMS will accept comments on the proposed rule until March 7.

Follow Virgil Dickson on Twitter: @MHvdickson


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