A recent ruling issued by the Centers for Medicare & Medicaid Services (CMS) aims to improve prescription drug price transparency and lower enrollee cost sharing in Medicare Advantage and Medicare Part D plans.
Under the ruling issued January 15, Part D plans must offer a real-time benefit comparison tool beginning January 1, 2023 that allows plan enrollees to obtain information about lower-cost alternative therapies included under the plan.
For example, if a Medicare prescription drug plan member is prescribed a particular medication, they will be able to use this tool to look up the copayment cost and see if a different option might be available under the plan (such as a generic version of the drug or another form of the drug such as a lotion instead of a tablet, for example).
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This change will allow patients to know how much their prescription costs and whether there are more affordable options at their disposal before they arrive at the pharmacy.
The new rule follows a similar requirement that went into effect on January 1, 2021 that requires Part D plans to support a real-time drug benefit search tool.
The new ruling also allows Part D plans to create an additional cost-sharing tier for their drug formularies. Currently, all drugs on the specialty (highest-cost) tier have the same level of cost-sharing. But under the new rule, plans may have an additional “preferred” tier that has a lower cost-sharing level for certain drugs than the specialty tier.
Lastly, Part D plans must begin disclosing to the CMS the pharmacy performance measures they use as part of their network agreements, which will help the CMS better understand the measures and report pharmacy performances publicly.
“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,” said outgoing CMS Administrator Seema Verma in a press release announcing the changes. “It will strengthen Part D plans’ negotiating power with prescription drug manufacturers so American patients can get a better deal.”
Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.
Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.
Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.
Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.
A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.
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