CMS Finalizes Drug Transparency, Pharmacy Quality Rules

CMS on Friday finalized a rule it estimates will save the federal government $75.4 million over the next decade in Medicare Advantage and Part D payments, with the agency crediting cost-savings to several measures enacted to curb prescription drug spending.

Under the new rule, CMS expanded drug and medication therapy management programs that require Medicare Part D plans to review potentially-risky opioid use trends with providers and patients. The final law also requires Medicare Part D sponsors to report payment suspensions against pharmacies facing fraud allegations to CMS, falling in line with the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, also known as the SUPPORT Act. The legislation also mandated Medicare Advantage and Part D plan sponsors report inappropriate opioid prescriptions and insurers’ actions to CMS via a secure internet portal.

In addition to cracking down on providers’ opioid prescriptions, the new rule includes steps to reduce out-of-pocket drug costs for Part D beneficiaries, standardize insurers’ process for reviewing pharmacy quality and allow enrollees to know more about their prescription drug costs in advance. The new rule follows an earlier set of Medicare Advantage and Part D updates CMS made in May 2020.

CMS will now require insurers to tell the agency how they calculate pharmacy performance measures by January 1, 2022, after complaints from the pharmaceutical industry the criteria used were unfair. CMS will publicly report the metrics to help insurers standardize the process for reviewing pharmacy performance, the agency said.

The federal agency will also give Part D plans the ability to create a “preferred” specialty tier of high-cost drugs with lower cost-sharing for enrollees by January 1, 2022. That change could help negotiate lower prices for expensive medications with drugmakers by promising them access to the so-called preferred tier.

Continuing the Trump administration’s efforts to reduce healthcare spending through increased transparency and lower drug costs, CMS wants Part D prescription drug plans to offer beneficiaries access to patient-specific drug costs in real-time by January 1, 2023. As an example, CMS said this tool will allow consumers to compare the price of similar, cholesterol-lowering drugs to see which requires the lowest individual copay. The final rule pushes this requirement back a year from its initial proposal.

“The changes in this final rule provide desperately needed transparency on the out-of-pocket costs for prescription drugs that have been obscured for seniors,” CMS Administrator Seema Verma said in a statement. “It will strengthen Part D plans’ negotiating power with prescription drug manufacturers so American patients can get a better deal.”

The final rule also updates Star Ratings and Quality Bonus Payment ratings, although CMS did not give details on the specific changes. The agency added that it is also working to codify policy changes related to supplemental benefits and provisions aimed at reducing the administrative burden for Programs of All-Inclusive Care for the Elderly, or PACE.


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