CMS to Allow Medicare Advantage Plans to Restrict Access to Drugs Covered Under Part B
When a person has Part B of Medicare typically any medication that is administered at the doctor’s office, or in the hospital, are covered by Medicare. This also was the case for Medicare advantage plans, aka Part C of Medicare. However, per CMS this is about to change for Medicare advantage plans. The new rule will allow Medicare advantage plan providers to not cover certain medications administered by a provider(doctor/hospital). For Example: Drugs used in durable medical equipment, anti-rejection drugs for people who had Medicare when they got a transplant, and some chemotherapy agents, as well as drugs that are both supplied by and administered by a provider. Here is a nice piece by Casey Schwarz of the Medicare Rights Group filing us in on the changes.
CMS to Allow Medicare Advantage Plans to Restrict Access to Drugs Covered Under Part B
This week, the Centers for Medicare & Medicaid Services (CMS) announced that next year, Medicare Advantage (MA) Plans will be able to limit options for people who get Part B-covered drugs by using many of the same tools plans currently use in Part D. The Trump administration argues that this will enable plans to negotiate better prices for the “preferred” medications – those that the plan will cover as a first-line treatment. Other drugs will only be covered if a person tries the preferred medication first and it doesn’t work or causes them harm, also known as step therapy.
Until now, MA plans were not permitted to place this type of restriction on medications covered under Part B. Part B drugs include drugs used in durable medical equipment, anti-rejection drugs for people who had Medicare when they got a transplant, and some chemotherapy agents, as well as drugs that are both supplied by and administered by a provider. Plans that have both MA and Part D coverage will be permitted to create combined step therapy requirements where a preferred Part B-covered medication must be tried before a non-preferred Part D-covered treatment.
These restrictions, which are common in Part D plans, can make comparing plans more difficult. While CMS requires plans to announce to enrollees that they intend to use this flexibility in the Annual Notice of Change, they do not require plans to send personalized or targeted notices to people currently taking, or who have a diagnosis that might require, the affected medications. Medicare Rights is concerned that it will be especially challenging to compare plans where Part B step therapy is used unless there are updates and improvements to the Medicare Plan Finder tool.
