Medicare Changes Opioid, Generic Policies for Part D Plans

Kerry Dooley Young

April 03, 2018

Medicare on Monday finalized new policies for opioid coverage under its Part D pharmacy plans while also taking steps that it says will make it easier for senior citizens to pay for their drugs. Such steps include increasing access to generic medicines.

The Centers for Medicare & Medicaid Services (CMS) used the regular annual update of policies for the Part D plans and the insurer-run Medicare Advantage program to take action regarding what the Trump administration has called a "scourge" of opioid addiction. CMS said it expects Part D plans to limit initial opioid prescriptions for the treatment of acute pain to no more than a 7-day supply, using an administrative tool known as a hard safety edit. There would be exceptions to the new CMS opioid policies for people being treated for cancer pain or for those receiving end-of-life care or living in long-term care centers, the agency said.

With more than 40 million senior citizens and people with disabilities enrolled in Part D plans, CMS could have significant influence on opioid prescriptions through the policy update that was finalized on Monday, which is known as a call letter. CMS said the new policies establish "a framework under which Part D plan sponsors may establish a drug management program for beneficiaries at risk for prescription drug abuse or misuse, or 'at-risk beneficiaries.' " The insurance plans will be expected to contact physicians when people enrolled in Part D are found to be taking notable amounts of opioids or are "obtaining them from multiple prescribers and multiple pharmacies who may not know about each other," the agency said.

CMS earlier announced its intention to make changes in opioid policies through the Part D update. In his State of the Union speech, President Donald J. Trump called for action to address the "terrible crisis of opioid and drug addiction." He also said in that speech that one of his administration's top priorities will be "fixing the injustice of high drug prices."

Lower Prices

In the 2019 Part D policy update, CMS signaled its continued interest in ways to give senior citizens more access to manufacturer rebates, as well as price concessions regarding the cost of medicines. CMS said it has already received more than 1400 responses to a previous request for information on this matter and is still soliciting feedback.

"We appreciate the detailed submissions from stakeholders," CMS Administrator Seema Verma said on a Monday night call with reporters.

The Trump administration seems to be putting pressure on insurers and other participants in the pharmaceutical supply chain to consider passing along discounts to consumers. In the call letter, CMS noted that the president's proposed fiscal 2019 budget proposal includes a discussion of the ability of Part D plans in managing discounts. In a document that details the president's request for members of Congress, the Department of Health and Human Services observed that "Part D sponsors are allowed, but not currently required, to apply rebates and other price concessions at the point-of-sale to lower the price upon which beneficiary cost-sharing is calculated.

"To date, sponsors have only very rarely elected to include rebates and other price concessions in the negotiated price at the point of sale," HHS said.

CMS already has decided to proceed through the 2019 update of Part D rules with steps that the agency said will help older Americans pay for their medicines. CMS now will allow certain low-cost generic drugs to be substituted into formularies at any point during the year, so people enrolled in Part D plans can more easily obtain them.

"As new generics come on the market, they can have immediate access to them and not have to wait until the open enrollment period," Verma said on the call.

The 2019 update also increases competition among Part D plans by removing the requirement that certain of these insurer-run programs "meaningfully differ" from each other, making more plan options available, CMS said. The agency said it will spur increased competition among pharmacies by clarifying the "any willing provider" requirement, thus expanding the number of pharmacy options that Part D customers have.

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