The Centers for Medicare & Medicaid Services (CMS) is addressing significant coverage gap changes created by the recently-passed Bipartisan Budget Act of 2018, according to CMS’s 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter.
According to CMS, coverage gap changes in the Budget Act may shift patients into the catastrophic tier—a type of high-deductible health plan for those younger than 30 years or those who qualify for a “hardship exemption”—and sway providers more toward brand-name drugs based on their coverage versus generic and other non-applicable drugs. This could reduce generic drug utilization, affect formulary inclusion, and lead to unnecessary medication substitutions.
During a presentation at AMCP Annual Meeting 2018, Melissa Andel, MPP, director of health policy at Applied Policy in Alexandria, Virginia, discussed CMS’ Medicare Part D Final Call Letter, released April 2.
CMS said it will remove drugs that are usually covered under Medicare Part B or otherwise rarely covered under Part D from the Formulary Reference File. With this, 376 drugs are slated for deletion, and injectable antineoplastics are the most-commonly affected drugs. CMS states that this change is aimed at reducing beneficiary confusion of coverage when a drug covered under Part B shows up on the Medicare Plan Finder (MFP).
Plan sponsors will also be expected to implement changes for opioid utilization management. All patients should be assessed for duplicate or key potentiator drugs (drugs that intensify the effects of a given drug), and opioid overuse will continue to be integrated into the Star Ratings system.
The following are future changes to MPF accuracy measures, which were largely previously proposed in the 2018 Call Letter, but not yet implemented:
- Factor both how much and how often prescription drug event (PDE) prices exceeded the prices reflected on the MPF
- Increase the number of claims included in the measure by expanding days’ supply (28-34, 60-62, or 90-100) and use PDE Pharmacy Service Type
- Round a drug’s MPF cost to two decimal places for comparison to its PDE cost
Other potential changes may include that the PDE cost must exceed the MPF cost by ≥$0.01 and modified measures will be published as a display measure for 2020 and 2021 and added to Star Ratings for 2022, pending rulemaking. Current MPF measures will continue to be included in the 2019 Star Rating.
Read the CMS Call Letter at cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf.
Presentation L6: Medicare Part D Call Letter Update. AMCP Annual Meeting 2018.