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Katiri Zuluaga

Manager, State Initiatives

CMS Finalizes Medicare Changes, Tightens Opioid Policies

April 12, 2018 | Medicare | Comments
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The Centers for Medicare and Medicaid Services (CMS) released final rules for Medicare Part D and Medicare Advantage (MA) plans for calendar year 2019 that are meant to tackle the opioid crisis and decrease drug costs. The CY19 Rate Announcement and Call Letter represents CMS’ priorities for the next year, and will implement new requirements on opioid prescribing and monitoring, require lower co-payments for prescription drugs under Part D, increase availability to generics and, hopefully, decrease costs for consumers and the federal government.

Opioid Prescribing Limits and Monitoring

In line with the Comprehensive Addiction and Recovery Act of 2016 (CARA), opioids will be designated as frequently abused drugs and Medicare beneficiaries who are flagged as at-risk for opioid misuse can be required to receive prescriptions from one prescriber and one pharmacy to deter receiving and filling multiple prescriptions. Health plans will be required to limit opioid prescriptions for acute pain to a seven-day supply and care coordination will be required for beneficiaries prescribed opioids for chronic pain.

Decreased Drug Costs
In CY 19, Medicare beneficiaries who receive low-income subsidies will have a lower co-payment for biosimilar drugs. Part D plans may immediately substitute generics for brand-name drugs. Beneficiaries will also be able to fulfill their prescriptions at any pharmacy, which will limit health plans and pharmacy benefit managers’ control over costs in Part D. These measures are intended to decrease cost-sharing for beneficiaries and increase savings for taxpayers.

Noticeably missing from the rules was a requirement for health plans in Medicare Part D to pass on prescription drug discounts and rebates to beneficiaries. CMS has made it clear they intend to take more steps to address drug pricing and are expected to actively shape policy initiatives in the future.