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CMS’ Medicare Part D and Medicare Advantage (MA) Proposed Rule Has Potential to Reduce Access to Care and Increase Administrative Burdens Through Increased Use of Prior Authorization and Step Therapy in MA and Part D

As we alerted you earlier this week, CMS released a proposed rule on Medicare Parts C and D aimed at reducing prescription drug costs. Specifically, it includes a formal proposal for CMS’ previously announced policy change—opposed by ASCRS and the ophthalmic community—that will allow for MA plans to begin using step therapy for Medicare Part B drugs beginning January 1, 2019.

For Part D, the proposed rule seeks to modify existing regulations related to so-called “protected class” drugs. Currently, all Part D plans are required to include all drugs in the protected classes (anticonvulsants, antidepressants, antineoplastics, antipsychotics, antiretrovirals, and immunosuppressants for treatment of transplant rejection) in their formularies and may not subject them to step therapy or prior authorization. Instead, CMS proposes to allow Part D plans to use step therapy and prior authorization. In addition, CMS proposes to give plans the authority to exclude some drugs from formularies that have experienced price increases or if there is a new formulation of an existing drug. The proposed rule also includes provisions to implement the recently enacted “gag clause” legislation that removes requirements that pharmacists not inform beneficiaries if they would pay less for a drug without using their benefit. Finally, it requires insurers to develop real-time programs that allow physicians to access plan and cost information for beneficiaries.

ASCRS has joined with the ophthalmic community and other specialty medical organizations to oppose the use of step therapy, as it can delay beneficiaries access to needed care, and we have joined with the entire medical community in seeking to reduce and streamline MA and Part D plans’ use of prior authorization. ASCRS will be submitting comments on the proposed rule in opposition to CMS’ planned expansion of these utilization and cost-containment tools. We will keep you updated.

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