Health Reform WK-EDGE Patients to count the costs, RX drug prices easier to find under final rule
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Wednesday, May 15, 2019

Patients to count the costs, RX drug prices easier to find under final rule

By Cathleen Calhoun, J.D.

A tool that gives electronic notification of prescription drug costs, and that works with a doctor’s electronic prescribing tool, will be required from Part D plans, and that’s just one of the changes.

An HHS final rule issued with the promise of greater transparency into the cost of prescription drugs in Medicare Part D. Changes under the rule include: (1) Part D plans must adopt tools with prescription drug prices to integrate with prescriber’s systems at the time of the writing of a prescription; (2) drug prices must be included in patients’ explanation of benefits; (3) codification of an exception related to protected class Part D drugs; and (4) Part D sponsors cannot prohibit or penalize a pharmacy from disclosing a lower cash price to an enrollee. The regulations are effective on January 1, 2020, except for the amendments to 42 C.F.R. §§ 422.629, 422.631, 422.633, 423.128, and 423.160, which are effective January 1, 2021 (Final rule, 84 FR 23832, May 23, 2019).

Exception related to protected class Part D drugs. The rule codifies existing policy, in effect since 2006, that permits Part D sponsors to impose, with some exceptions, prior authorization and step therapy requirements for beneficiaries initiating therapy (i.e., new starts) for five of the six protected classes. Those five protected classes are antidepressants, antipsychotics, anticonvulsants, immunosuppressants for treatment of transplant rejection, and antineoplastics. No prior authorization or step therapy is allowed for the sixth protected class: antiretrovirals.

Tools and E-Prescribing in Part D. The rule requires Part D plans to adopt a Real Time Benefit Tool (RTBT), capable of integrating with at least one prescriber’s ePrescribing system or electronic health record (EHR), no later than January 1, 2021. Clinicians will be able to give information on out-of-pocket costs for prescription drugs and discuss the costs with patients at the time of writing a prescription.

Part D explanation of benefits. The Part D Explanation of Benefits that Part D plans send members each month must contain drug price increases and lower cost therapeutic alternatives, effective January 1, 2021.

Gag clauses. Part D sponsors cannot keep a pharmacy from disclosing a lower cash price to an enrollee through penalizing the pharmacy or through stating that it is prohibited.

MainStory: TopStory FinalRules AgencyNews MedicarePartDNews

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