The Centers for Medicare and Medicaid Services (“CMS”) issued a final rule and a related fact sheet for the Medicare Advantage and Part D programs. The rule aims to continue efforts toward greater transparency and lower prices for prescription drugs. The content of such rules are not finalized until their publication in the Federal Register. This rule is due to be published on May 23. Among the highlights, the final rule:

  • Requires Part D plans to adopt “Real Time Benefit Tools” that are capable of integrating with at least one provider’s ePrescribing system or electronic health record. Those tools must be in place by January 1, 2021.
  • Medicare Advantage plans are permitted to continue using step therapy for Medicare Part B drugs. Step therapy usually requires patients to use less costly drugs before moving to a different, more expensive drug.
  • The rule implements legislation banning pharmacy “gag clauses” that restrict Part D sponsors from prohibiting or penalizing a pharmacy from disclosing a lower price to an enrollee. The rule also requires explanation of benefits for Part D to include drug price increases and lower cost therapy alternatives.