CMS will apply pharmacy price concessions at point of sale

After unsuccessful attempts to lower Medicare Part D beneficiary cost-sharing, the Centers for Medicare & Medicaid Services (CMS) will finally wrap up a proposal to apply pharmacy price concessions at the point of sale, Good Day BIO reported.

Dan Durham, the Executive Vice President for Health Policy at the Biotechnology Innovation Organization (BIO), and Andrew Cosgrove, BIO’s Senior Director, described this as “notable progress in BIO’s ongoing efforts to reduce beneficiary out-of-pocket spending.”

CMS’ final rule revising Medicare Advantage (MA) and Part D regulations for 2023, which will apply pharmacy price concessions at the point of sale beginning in 2024, was issued on Friday and is due to be published in the Federal Register on Monday.

CMS Administrator Chiquita Brooks-LaSure pointed out that “this rule improves the health care experience and affordability for millions of people with MA and Part D coverage, including dually eligible individuals, and provides needed support to populations often left behind,” according to a CMS statement. The rule also “requires all MA special needs plans to annually assess certain social risk factors for their enrollees because identifying social needs is a key step to delivering person-centered care,” the statement said.

This measure, according to CMS estimates, will save beneficiaries $26.5 billion over 2024-2032.

BIO supports the concession

Good Day BIO stressed that this change “may have implications for further policy initiatives to reduce beneficiary out-of-pocket spending.”

BIO supports all such concessions—including negotiated rebates—at the point of sale as a way to lower beneficiary cost-sharing and will continue to advocate “for this change to further reduce patient prescription out-of-pocket costs” and for “regulations that prohibit discriminatory benefit design that harms the sickest patients who need the high-value treatments,” Good Day BIO said.

Demanding that “insurers offer standardized health plan options alongside any non-standardized Qualified Health Plans (QHPs), specifically flat copays for drugs on all tiers of coinsurance,” the Notice of Benefits and Payment Parameters is a positive step for patients, Good Day BIO said.

It also strengthens the enforcement of policies against discrimination in plans, warning pharmacy benefit managers and insurers “against designing plans that discriminate against people with chronic health conditions by placing all or most drugs to treat a certain condition at the highest tier,” Good Day BIO said.

This change, as Good Day BIO noted, “will ensure that insurance works like it should and lower patients’ costs at the pharmacy,” which BIO has long advocated for, and “will limit patient copays and allow for more drugs to be accessed outside of a deductible.”

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