CMS 2022 Final Rule Requires Part D Real-Time Drug Benefits Tool

CMS has released its final rule for Contract Year 2022 Medicare Advantage and Part D which requires Part D plans to offer a real-time benefits comparison tool.

The agency estimated that the rule’s alterations would save the federal government $75.4 million over the course of the next decade.

“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 CMS Administrator Seema Verma. “It will strengthen Part D plans’ negotiating power with prescription drug manufacturers so American patients can get a better deal.”

The rule mirrored changes which went into effect on January 1, 2021 that required Part D plans to support a prescriber real-time drug benefit tool as well a similar requirement in the Consolidated Appropriations Act of 2021.

The benefit tool aimed to ensure that enrollees can anticipate their prescription drug spending when they go to a pharmacy to pick up their medications. Furthermore, it allowed Part D plan enrollees to compare prescription drugs based on cost and to select lower-cost alternatives.

The final rule also allowed Part D plans to have a second “preferred” specialty drug tier. Drugs on this tier would be less expensive for members than the other specialty tier. Payers use these tiers to negotiate with manufacturers.

“This change gives Part D plans more tools to negotiate better deals with manufacturers on the highest-cost drugs and lower out-of-pocket costs for enrollees in exchange for placing these products on the ‘preferred’ specialty tier,” explained the press release.

In response to pharmacies’ complaints that Part D plans were setting unattainable performance metrics, CMS also required Part D plans to show their pharmacy performance metrics to the agency.

In addition to protecting pharmacies from unfair quality measures, CMS anticipated that this policy would allow for greater public transparency about pharmaceutical standards.

The rule’s fact sheet added that CMS will enact changes to the star ratings system for Medicare Advantage and Part D prescription drug plans. These changes provided measure updates, clarified technical details for score calculations for consolidated plans and other unique scenarios, and explained quality bonus payment rating rules for new contracts.

Furthermore, CMS also included provisions to ensure that Part D plans are engaged in the agency’s fight against the opioid epidemic. Part D plans will be required to educate enrollees about opioids, alternative pain management solutions, and controlled substance prescription drug disposal.

CMS also finalized policies that aim at reducing administrative burden for the Programs of All-Inclusive Care for the Elderly (PACE).

In general, these changes will go into effect in plan year 2022.