{"id":6817,"date":"2019-02-11T07:20:28","date_gmt":"2019-02-11T07:20:28","guid":{"rendered":"http:\/\/www.medicalbillersandcoders.com\/pharmacy-billing-services-blog\/?p=6817"},"modified":"2025-05-19T09:08:40","modified_gmt":"2025-05-19T09:08:40","slug":"pharmacy-medical-billing-lower-drug-prices-in-medicare-advantage-and-part-d","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/pharmacy-billing-services-blog\/pharmacy-medical-billing-lower-drug-prices-in-medicare-advantage-and-part-d\/","title":{"rendered":"Pharmacy medical billing: Lower Drug Prices in Medicare Advantage and Part D"},"content":{"rendered":"

CMS is allowing Medicare Advantage plans to cross negotiate Part D drug prices Starting in 2019, insurers may use step therapy to choose the least expensive drug first before moving on to another prescription.<\/p>\n

For the first time in the history of healthcare US, Medicare<\/a> Advantage plans that also offer a Part D benefit have now the option of cross negotiating for Part D drugs to get the lowest prices.<\/p>\n

Starting January 1, 2019, plans may ensure that a beneficiary who is newly diagnosed with a condition begins treatment with a cost-effective biosimilar before progressing to a more costly drug therapy if the initial treatment is ineffective.<\/p>\n

The key changes of the proposed rule are as follows:<\/strong><\/h2>\n

Implementing the broader use of prior authorization and step therapy for protected class drugs, determining the use for protected class indications.<\/p>\n

Under CMS\u2019 proposal, PA requirements would be allowed for any protected class drug with more than one medically-accepted indication to determine that the drug is being used for a protected class indication, regardless of its status as a new start or existing therapy.<\/p>\n

CMS would also allow indication-based formulary design and utilization management for protected class drugs.<\/p>\n

Providing Part D plans with greater flexibility to negotiate discounts for drugs in \u201cprotected\u201d therapeutic classes, so beneficiaries who need these drugs will see lower costs;<\/p>\n

Requiring Part D plans to increase transparency and provide enrollees and their doctors with a patient are out-of-pocket cost obligations for prescription drugs when a prescription is written;<\/p>\n

Codifying a policy similar to the one implemented for 2019 to allow \u201cstep therapy\u201d in Medicare Advantage for Part B drugs, encouraging access to high-value products including biosimilar; and<\/p>\n

Implementing a statutory requirement, recently signed by President Trump, that prohibits pharmacy gag clauses in Part D.<\/p>\n

Exclude the protected class drug from a formulary if the drug represents only a new formulation of an existing single-source drug or biological product, regardless of whether the older formulation remains on the market.<\/p>\n

This proposal is intended to address the situation, for example, where a manufacturer introduces a more expensive extended-release version of a drug to the market while also withdrawing from the market the predecessor immediate release version when no generic was available.<\/p>\n

Such a scenario could arise with a protected class drug that might leave Part D sponsors with no option but to add the new, more expensive product to their formularies and could result in increased costs for Part D enrollees and the Part D program.<\/p>\n