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Rule Change Takes on Medicare Drug Price Transparency

A recent rule change aims to improve prescription drug price transparency for Medicare Part D and Medicare Advantage plan members.

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).

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. 

New Medicare rules may help beneficiaries navigate drug costs

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.”