The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule and the Advance Notice Part II to further advance the agency’s efforts to strengthen and modernize the Medicare Advantage and Part D prescription drug programs. These changes would lower the beneficiary cost sharing on more expensive prescription drugs, promote the use of generic medications, and allow beneficiaries to know in advance and compare their out-of-pocket payments for different prescription drugs.

The changes advance President Trump’s Executive Orders on Protecting and Improving Medicare for Our Nation’s Seniors and Advancing American Kidney Health, as well as several of the CMS strategic initiatives, according to the agency. With these changes, the plan revenue is expected to increase by 0.93%.

The proposed rule would require Part D plans to offer real-time drug price comparison tools to beneficiaries starting January 1, 2022 so that consumers can buy lower-cost alternative therapies under their prescription drug benefit plan. Using these tools, patients will be able to know what they will need to pay before they are standing at the pharmacy cash register. In addition, pharmaceutical companies and coverage plans would have to compete on the basis of the costs that patients face for their prescription drugs.

Beneficiaries are able to choose the prescription drug plan that best meets their needs in the Medicare Part D program. Many prescription drug coverage plans place medications into different “tiers” based on their formularies; and drugs that are placed on a plan’s specialty tier—which has the highest cost medications—have the same level of cost sharing. With the proposed rule, a second “preferred” specialty tier in Part D with a lower cost sharing amount will be allowed. Moreover, the proposal is designed to give Part D plans more tools to lower out of pocket costs for enrollees.

Under the Part D program, plans currently do not have to disclose to CMS about the measures they use to evaluate pharmacy performance in their network agreements. With the new rule, it would be required for Part D plans to disclose this kind of information to enable CMS to track how plans are measuring and applying pharmacy performance measures. CMS will also be able to report this information publicly to help increase transparency on the process.

The proposed rule by CMS implements several provisions of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act that requires Part D plans to educate beneficiaries on opioid risks, alternate pain treatments, and safe disposal of opioids.

The rule also expands drug management programs and medication therapy management programs, through which Part D plans review with providers opioid utilization trends that may put beneficiaries at-risk and provide beneficiary-centric interventions.

In the Advance Notice, CMS is seeking help on potentially developing measures of generic and biosimilar utilization in Medicare Part D as a part of the plan’s star rating. The Star Ratings system helps anyone affected by Medicare compare the quality of health and drug plans being offered to them.

Additionally, under the proposed changes, Medicare Advantage beneficiaries are able to access additional telehealth benefits not offered under Medicare Fee-for-Service program, giving patients the option to receive health care services from more convenient locations.


Proposed Changes to Medicare Advantage and Part D Will Provide Better Coverage, More Access and Improved Transparency for Medicare Beneficiaries. Centers for Medicare and Medicaid Services [email]. Sent February 5, 2020. Accessed February 6, 2020.