CMS Proposes Changes to Medicare Prescription Drug Rules for 2020

The U.S. Centers for Medicare & Medicaid Services (CMS) has proposed revisions to expand insurers' authority for negotiating lower prices on certain prescription drugs, reports BioSpace . One proposal would reduce prices for Medicare Part D plans via negotiated discounts for "protected" therapeutic areas. This would permit sponsors to deploy broader use of prior authorization and step therapy for protected class drugs, including to ascertain use for protected class indications and exclude such drugs from a formulary if the medication represents only a new formulation of an existing single-source drug or biological product. Also authorized would be the exclusion of a protected class drug from a formulary if its price rose beyond a certain threshold over a specific look-back period. Drug classes specified by CMS include antidepressants, antipsychotics, anticonvulsants, immunosuppressants for treatment of transplant rejection, and antiretrovirals. Another proposal would reclassify negotiated price as the baseline payment to a pharmacy, which the agency noted is often increasingly higher than the final payment "unless it incorporates the large price concessions that result from these arrangements." Finally, the agency will provide a pathway that will enable Part D providers to update e-prescribing methods that will let physicians and prescribers know when lower-cost alternatives are available under the insurance program.