Medicare Advantage Rx Drug

Republican lawmakers in an Aug. 26 letter to the Congressional Budget Office (CBO) criticized the rollout of a demonstration program that is intended to ease Medicare Part D premiums for beneficiaries and help stabilize the market but could cost taxpayers billions of dollars. It is the latest salvo from politicians since CMS announced the Part D Premium Stabilization Demonstration on July 29, the same day it revealed the national average monthly bid amount (NAMBA) would increase by nearly 180% next year.

Debra Devereaux, an executive consultant with Rebellis Group, speculates that some stand-alone Prescription Drug Plans (PDPs) “must have had eye-popping bids” to prompt CMS to launch the program. She suggests that PDPs likely increased their premiums for next year to offset major changes that are part of the Inflation Reduction Act (IRA) and will result in plans shouldering significantly more financial risk. The demonstration program is only for PDPs and does not include Medicare Advantage Prescription Drug (MA-PD) plans.

Now that CMS has revealed the prices of the first 10 drugs subject to Medicare price negotiation, all eyes are on how Part D plans will cover those drugs on their formularies in 2026, when the new prices go into effect.

To that end, a recent poll from Zitter Insights offers some clues about how payers and PBMs are thinking about this thorny question.

Now that CMS has revealed the prices of the first 10 drugs subject to Medicare price negotiation, all eyes are on how Part D plans will cover those drugs on their formularies in 2026, when the new prices go into effect.

To that end, a recent poll from Zitter Insights offers some clues about how payers and PBMs are thinking about this thorny question.

The flash poll was conducted after CMS revealed the results of the first round of the Medicare Drug Price Negotiation Program, which was authorized by the Inflation Reduction Act. Through that process, Medicare for the first time set a Maximum Fair Price (MFP) for 10 branded drugs selected due to their high cost and lack of generic or biosimilar competition.

Amazon Pharmacy revealed earlier this month that its RxPass subscription savings program is now available to “more than 50 million Medicare beneficiaries,” allowing those who are Prime members to get 60 common generic medications delivered for a $5 monthly fee. Industry experts tell AIS Health that they can see the appeal in such an offering — including both convenience and potential cost savings — but they aren’t expecting the newly expanded service to significantly impact the Medicare Part D space.

“To be very honest, when I read the news, I didn’t really give it too much of a second glance,” says Marc Guieb, Pharm.D., a consultant at Milliman. “In terms of big-picture market stuff, I don’t think this really is going to change much or have any sort of tangible effects.”

Over half of Medicare Advantage enrollees were in plans that applied step therapy to the 10 most commonly used rheumatoid arthritis (RA) medications covered by Medicare Part B in 2023, according to a recent Avalere analysis.

Since 2019, CMS has given MA plans the ability to use step therapy protocols — meaning a patient may be required to try a less expensive drug before moving to the more expensive one — for physician-administered and other Part B medications. Avalere analyzed MA plans’ annual medical policy and formulary restrictions for 22 RA drugs from 2018 to 2023 and found that the percentage of MA beneficiaries in plans that use step therapy has increased steadily since 2019. For two of the drugs studied, 78% of enrollees were in MA plans that applied step therapy in 2023.

Over half of Medicare Advantage enrollees were in plans that applied step therapy to the 10 most commonly used rheumatoid arthritis (RA) medications covered by Medicare Part B in 2023, according to a recent Avalere analysis.

Since 2019, CMS has given MA plans the ability to use step therapy protocols — meaning a patient may be required to try a less expensive drug before moving to the more expensive one — for physician-administered and other Part B medications. Avalere analyzed MA plans’ annual medical policy and formulary restrictions for 22 RA drugs from 2018 to 2023 and found that the percentage of MA beneficiaries in plans that use step therapy has increased steadily since 2019. For two of the drugs studied, 78% of enrollees were in MA plans that applied step therapy in 2023.

For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month.

Created under the Inflation Reduction Act, the M3P requires stand-alone Prescription Drug Plans and Medicare Advantage Prescription Drug plans to give enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments versus paying the full amount at the pharmacy. Program participants will pay $0 at the pharmacy but receive a monthly bill from their Part D carrier, which must reimburse the pharmacies in full.

Medicare Part D plans are likely to revise their biosimilar formulary management policies as a result of recent regulatory changes, not least the Inflation Reduction Act (IRA). Part D payers will also be on the hook for a greater share of the cost of biosimilars going forward.

A study in Health Affairs released in May makes the case that the longstanding gap in the coverage of biosimilar products between employer-sponsored insurance plans and Medicare Part D plans is likely to shrink in 2025, when several key components of the IRA take effect.

This article originally appeared as part of the May 16 issue of Radar on Medicare Advantage.

For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month.

As Medicare Part D sponsors consider critical steps to setting up the new Medicare Prescription Payment Plan (M3P), CMS is weighing feedback from stakeholders on various aspects of the program, from beneficiary communications to pharmacy interactions. And some warned that potential beneficiary confusion may lead to increased complaints that impact plans’ Star Ratings.

The M3P, which takes effect on Jan. 1, 2025, requires both stand-alone Prescription Drug Plan and Medicare Advantage Prescription Drug carriers to give beneficiaries the option to spread their pharmacy costs over the plan year via a capped monthly payment. CMS in February issued its second draft guidance on the M3P and asked for comments no later than March 16. CMS plans to release the final guidance this summer. The agency sought comment on model materials issued through an Information Collection Request (ICR), including a standardized notice that plans would be required to use for targeted outreach to enrollees who are likely to benefit from the M3P. The initial 60-day comment period on the model materials ended April 29; CMS said it expects to issue a second, 30-day comment period in Spring 2024.