CMS proposes new tool to help Part D plans combat opioid crisis, provide more Medicare Advantage flexibility

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CMS has proposed allowing mid-year changes to drug formularies when a new generic medication becomes available.

CMS has issued a proposed rule that would update the Medicare Advantage and Part D programs, including changes aimed at combatting the opioid crisis and increasing flexibility in MA plan design. 

The Centers for Medicare & Medicaid Services new proposed rule (PDF) also aims to make it easier for seniors enrolled in Medicare Part D to access affordable prescriptions. Plus, in Medicare Advantage, it makes changes that seek to combat fraud.

Rebates and price concessions to payers and pharmacy benefit managers have grown by more than 20% a year between 2010 and 2015, the agency noted in the rule, but those savings are rarely passed along to patients. If the rule is finalized, payers and PBMs could be required to funnel those savings to members. 

CMS also proposed allowing midyear changes to drug formularies when a new generic medication becomes available, which will offer flexibility to prescribe appropriate and low-cost medications to patients, the agency announced

Further, CMS wants to offer Medicare Part D enrollees more pharmacy options, and would revise the program's pharmacy limitations to include more local pharmacies and other options, like mail order services. 

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CMS said it would also provide "an important new tool" to combat the opioid epidemic if the rule is finalized. It would allow Part D plans to require that some beneficiaries acquire opioids from specific prescribers and pharmacies to avoid doctor-shopping to acquire the drugs. 

CMS is requesting comment and information on its proposals, including how the changes can best benefit beneficiaries while minimally impacting taxpayers, according to the announcement. 

Proposed changes to Medicare Advantage plans 

The rule aims to provide Medicare Advantage payers with more flexiblity to design benefits packages to fit the specific needs of individual enrollees, according to a fact sheet from CMS. It would reduce cost-sharing for customized benefits and allow for different cost-sharing in the case of beneficiaries that meet specific criteria. 

"These changes give MA organizations new tools to improve care and outcomes for the most vulnerable enrollees," according to the fact sheet. 

The number of MA plans available to enrollees would increase from about 2,700 to 3,100. 

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CMS is also proposing to expand the definition of quality improvement for MA plans to include fraud detection activities by changing the medical loss ratio requirements for these plans, according to the rule. The agency said the change should help combat fraud. 

It also seeks to reduce the administrative burden in reporting MLR data for both MA and Medicare Part D.