CMS issues monthly drug payment program final guidance 

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The Centers for Medicare and Medicaid Services has released the final part one guidance for the new Medicare Prescription Payment Plan.

The guidance for Medicare Part D plan sponsors is to ensure they successfully implement the Medicare Prescription Payment Plan and effectively build the necessary infrastructure, CMS said.

The Medicare Prescription Payment Plan, which begins in 2025, will give people with Medicare Part D prescription drug coverage the option to pay out-of-pocket costs in monthly payments spread out over the year, rather than requiring full payment at the pharmacy counter. 

WHY THIS MATTERS

Today's final part one guidance focuses on outlining the necessary operational requirements for Medicare Part D plan sponsors. 

It requires Part D sponsors to notify a pharmacy to provide information on the program for anyone who meets a $600 out-of-pocket threshold based on a single prescription at the point-of-sale. 

This required notification is in addition to the communications that will be provided to people with Medicare Part D before and during the coverage year, as outlined in the draft part two guidance for the program published this past February 15. 

CMS said this multipronged approach will help ensure that those most likely to benefit from the program get the information they need to determine whether or not to participate in the Medicare Prescription Payment Plan. It also reduces the risk of identifying Part D enrollees for whom this program may not be helpful.

The guidance also finalizes the requirement that Part D sponsors must process election requests within 24 hours during the plan year.

Today's guidance is accompanied by the release of an Information Collection Request (ICR) for the Medicare Prescription Payment Plan, which includes model materials for Medicare Part D plan sponsors to use when communicating to Part D enrollees about the program. 

CMS is seeking feedback on the materials through the ICR public comment period, which ends April 29. In addition, the draft part two guidance for the program is open for comment until March 16.

THE LARGER TREND

The final part one guidance considered public comments received in response to the draft part one guidance released on August 21, 2023.

It is another implementation of President Biden's prescription drug pricing law, the Inflation Reduction Act of 2022.

Other Inflation Reduction Act provisions include:

• As of January 1, people enrolled in Medicare Part D who have very high drug costs will, for the first time, no longer have to pay cost sharing for their prescription drugs in the catastrophic phase of the program.
• Starting in 2025, all individuals with Medicare Part D will have their out-of-pocket prescription drug costs capped at $2,000.
• On January 1, 2024, the law expanded eligibility for full benefits under the Low-Income Subsidy program (LIS or "Extra Help") under Medicare Part D. Benefits include no deductible, no premiums and fixed, lowered copayments for certain medications. 
• Medicare Part D beneficiaries who receive insulin delivered through a pump pay no more than $35 for a month's supply of each covered insulin product.
• Recommended vaccines are covered at no cost for people with Medicare prescription drug coverage.  

ON THE RECORD

"The guidance released today is an important step in helping certain people with Medicare prescription drug coverage who have high up-front drug costs to spread out their cost sharing over the year," said CMS Administrator Chiquita Brooks-LaSure. 

"People in Medicare who face very high out-of-pocket costs at the start of the year will be relieved to hear that the drug pricing law will make those costs more manageable with the arrival of the Medicare Prescription Payment Plan," said Dr. Meena Seshamani, CMS deputy administrator and director of the Center for Medicare. "This part one guidance will ensure a seamless experience for people with Medicare by setting clear expectations for plans to create a uniform experience for people who opt into the program."

Email the writer: SMorse@himss.org