CMS Proposes Part D Drug Benefit Tool for 2022
Could it be that fuss created over rising drug prices will change things for 2022?
We at Doctor’s Choice as well as what you’ve heard in the news, have all been talking about the steady increase in Part D prescription costs over the last 5 years or so. In closing out it’s contracts for the 2022 year, CMS released a final rule that will restructure Part D prescriptions.
CMS is taking a new look at drugs and drug coverage. The 2020 feedback as to costs or drugs, the kickback models for prescribing a drug that falls in the “top 50” most expensive, and the opioid crisis have brought CMS to think twice about how drugs are priced, reimbursed and covered.
The new rule will mandate:
Part D Income Related Monthly Adjustment Amount (IRMAA) calculation update
Applicable starting March 22, 2021
Beneficiary Part D real-time benefit tool (RTBT)
Beginning January 2023
Comprehensive Addiction and Recovery Act of 2016 Part D drug management programs
January 2022
The Part D Income Related Monthly Adjustment Amount relates to the classification of Part D drugs. As we discussed in our Most Favored Nations article, there is a top 50 drugs that are the most expensive and of course, the most often prescribed. These drugs send a kickback to prescribers not only by the initial prescription, but each time the client needs to renew that prescription, the provider gets another kickback fee up to 106% of the market value for that drug. Obviously, if unwatched this would continue to drive the price of prescriptions into the heavens, but due to the fuss and facts, CMS is changing their cost structure for the “main offender” drugs.
Now, Part D sponsors will need to create two tiers for drugs, one that is “speciality” and one that is generic or a comparable version that costs less. If a drug is placed on a “speciality” tier, the payer or provider will also need to create a secondary tier that is subject to the ingredient threshold established through the requirements of the CMS formulary review process. In order to protect Part D beneficiaries, CMS is codifying the maximum allowable amount of cost sharing for each drug in the tiers, with the “preferred” tier being the lower cost. The new limit to cost sharing will be 25%-33%, depending on if the plan includes a deductible. The “specialty tier” guidelines are provided by CMS and will be updated annually based on ingredient prices. The lower threshold medications will be at a lower-cost sharing due to the reduced cost.
Another detail of the rule aims to increase transparency of the Part D plan star rating systems. The clarifications provide technical criteria for how plans are rated and scored, how payments are issued, and how new contracts are acquired.
On that point, the Beneficiary Real-Time Benefit Tool requires Part D sponsors to implement a tool to allow Medicare enrollees to assess the costs of Part D prescriptions. The tool requires its own application and could be used across phones, tablets, desktops, etc. as long as the patient is signed into the secure portal. The real-time information would provide the patient with accurate and reliable information on the costs of drugs and benefit information so they can make informed real-time decisions. Not only is this good for patients but it’s estimated to save the Federal Government $75.4 million over the next decade. (healthpayerintelligence.com)
Lastly the Addiction Recovery Act of 2016 created infrastructure now extending to Medicare Beneficiaries who receive opioids. The Recovery Act created due to the opioid crisis, recognizes that many prescriptions for Medicare beneficiaries are opioids and something needs to be done. We saw that when left to their own devices, pharmaceutical industries push their prescriptions via the fee-for -service method where physicians would receive benefits for administering opioids to their patients. Recognizing the crisis of addiction that our country faces, and how a good deal of that was created by prescribing physicians, there is now a measure in place that flags all those receiving opioid medications. Now pharmacies and plan sponsors will need to submit information for investigation to make sure there is not fraud, waste or abuse. For those whose cases are flagged for abuse, counseling services will be implemented as well as recovery therapies to replace the drugs in use.
