Medicare Rights Comments on CMS Proposal to Give Drug Plans Additional Flexibility

The Medicare Rights Center recently responded to a proposed rule from the Centers for Medicare & Medicaid Services (CMS) that would, in part, allow Part D and Medicare Advantage (MA) prescription drug plans greater flexibility in managing their formularies.

According to CMS, the proposed policies are intended to “remove administrative hurdles to offer lower cost options to seniors and provide support for private sector partners by providing them the tools to lower the cost of prescription drugs.”

While we agree with the need to address high and rising drug prices, we strongly disagree with the agency’s proposed approach, which seeks to do so by weakening the protected classes protections and permitting step therapy for Part B drug coverage. Such changes have the dangerous potential to disrupt or even end access to some medications for people with Medicare.

Currently, Medicare drug plans are generally required to cover all of the available drugs in six categories known as the “protected classes.”: These categories include anti-depressants, antipsychotics, anticonvulsants, immunosuppressants for transplant rejection, antiretrovirals and antineoplastics. Under the proposed rule, plans would be able to limit or exclude coverage of drugs in the protected classes. Medicare Rights continues to find this suggested change extremely troubling, as these medications are not easily substituted and interruptions in drug therapies could have significant individual and public health consequences.

Similarly, CMS’ proposal to allow MA plans to utilize step therapy on Part B drugs would also have negative impacts on beneficiary health and well-being, by limiting beneficiary access to these medications—including in the treatment of life-threatening conditions like cancer—and by making comparing plans even more difficult.

CMS suggests that Medicare’s appeals and exceptions processes would be sufficient to protect beneficiaries from the proposed rule’s potential access issues. However, the current system is deeply flawed, rendering it an inadequate safeguard. Forcing consumers who rely on a protected class drug into this process would exacerbate and amplify these flaws, to the detriment of some of the sickest Medicare beneficiaries. Similarly, the proposed alignment of the appeals processes for Part B drugs and Part D would be insufficient to resolve issues likely to result from the imposition of step therapy on Part B drugs. We cannot support weakening beneficiary protections in reliance on a frayed safety net.

While Medicare Rights appreciates the need to control drug costs, CMS must not impede beneficiary access to needed medications in pursuit of this goal. We urge CMS to withdraw this proposal and work toward solutions that provide general relief from high list prices and out-of-pocket costs, rather than approaches that put people with Medicare at risk of losing access to therapies that protect beneficiary health.

Read Medicare Rights’ comments.