CMS Proposed Rule Addresses Rx Pricing in Medicare Advantage and Part D

The Centers for Medicare & Medicaid Services (CMS) released detailed and specific requirements on November 20, 2018, in the “Part D Drug Management Program Policy Guidance.” The release includes the “how to” for implementation of Drug Management Programs (DMPs), which are required beginning January 1, 2022. CMS expects all Part D sponsors to implement DMPs in 2019, including Programs of All-Inclusive Care for the Elderly (PACE) plans and Employer Group Waiver Plans (EGWPs). CMS describes programming that intends to strike a balance between beneficiary access and beneficiary risk due to use of frequently abused drugs (FADs). Of particular interest are the following:

  • Standard beneficiary notice of intent to limit access of FADs is being finalized through the Office of Management and Budget (OMB), and Part D sponsors are required to use these notices when available.
  • Beneficiaries must meet criteria in the quarterly Overutilization Monitoring System (OMS) reports to be potential at-risk beneficiaries (PARBs), however, plans can institute more frequent monitoring (monthly).
  • Part D sponsors must review all beneficiaries meeting minimum OMS criteria and respond to CMS.
  • Members identified as meeting criteria will be enrolled in case management with prescriber engagement to determine if the member is indeed at risk.
  • Members’ access can only be limited after notification.
  • Options available include beneficiary-specific point of sale edits, limitation to network prescriber, and/or limitation to network pharmacy.
  • Members generally may select the prescriber and pharmacy.
  • Case management must be conducted by a licensed professional – “generally a physician or other health care professional with expertise to conduct medical necessity reviews related to potential opioid overutilization.”
  • Having a cancer diagnosis does not exempt a beneficiary from DMP enrollment only “active cancer-related pain.” Only cancer survivors with chronic pain, in active remission, or under cancer surveillance would not be exempt.




Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe

Learn how a single platform designed specifically for Medicare can streamline enrollment and offer a better way to deliver a return on your plan’s investment. Click here


Debra Devereaux
Debra Devereaux

Deb Devereaux is Senior Vice President of Pharmacy and Clinical Solutions at Gorman Health Group (GHG). In this role, she is responsible for leading a team of pharmacists and business analyst consultants with broad health plan, Centers for Medicare & Medicaid Services (CMS) and Pharmacy Benefit Manager (PBM) experience. Deb brings GHG clients more than eight years of Medicare Part D operations expertise. Read more

No Comments Yet

Leave a Reply

Your email address will not be published.