Part D donut-hole: CMS revises plan guidance

The Centers for Medicare and Medicaid Services (CMS) has released a memorandum providing Medicare Part D (prescription drug) sponsors with revised guidance for the Medicare Coverage Gap Discount Program. The revised plan guidance guarantees that Medicare Part D enrollees will reap 50 percent savings on brand-name drugs, as well as some authorized generic drugs, during the 2011 coverage gap (aka donut hole), according to CMS. The revised guidance incorporates public comments on the draft guidance that was released on April 30, clarifying the implementation procedures for the discount program. CMS also provides responses to the public comments.

Among the tidbits to be gleaned:

  • CMS plans to publish the revised model explanation of benefits (EOB) in June.
  • CMS will work with the Food and Drug Administration "to make information on NDCs [national drug codes] more transparent and readily available to the public so that Part D sponsors can accurately determine which products represent applicable drugs subject to the discount, and will do our best to make it clear to the public which labeler codes are covered by agreements and which labeler codes are not."
  • CMS will consider creating additional notice requirements and developing model letters and notices that tell beneficiaries about key aspects of the discount program.
  • CMS has determined that employer group waiver plans (EGWPs) are included in the discount program and in 2011 will allow EGWPs to participate "if they can attest and/or otherwise demonstrate that their beneficiaries have cost-sharing between the plan initial coverage limit (ICL) and the catastrophic threshold and that they will apply any supplemental benefits before determining the applicable discount that will be reported on the PDEs [prescription drug event records]."

To learn more:
- read the CMS press release
- read the guidance from CMS
- register for the June 1 conference here