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Prescription Drug Changes for Medicare Advantage and Part D Plans

​The Centers for Medicare & Medicaid Services (CMS) issued a final rule to allow Medicare enrollees to know in advance and compare their out-of-pocket payments for different prescription drugs. The changes apply to the 2022 plan year and are expected to save $75.4 million over ten years.

The final rule will require Part D plans to offer a real-time benefit comparison tool starting January 1, 2023, so enrollees can obtain information about lower-cost alternative therapies under their prescription drug benefit plan. Enrollees will be able to compare cost sharing to find the most cost-effective prescription drugs for their health needs. CMS already requires Part D plans to support a prescriber real-time drug benefit tool that went into effect January 1, 2021.

In the Medicare Part D program, enrollees choose the prescription drug plan that best meets their needs. Many plans offering prescription drug coverage place drugs into different “tiers” on their formularies. Today, all drugs on a plan’s specialty tier – the tier that has the highest-cost drugs – have the same level of cost sharing. Under the final rule, CMS is allowing Part D plans to have a second, “preferred” specialty tier with a lower cost sharing level than their other specialty tier. This change gives Part D plans more tools to negotiate with manufacturers on the highest-cost drugs and lower out-of-pocket costs for enrollees in exchange for placing products on the “preferred” specialty tier.

A fact sheet on the Contract Year 2022 Medicare Advantage and Part D Final Rule (CMS-4190-F2) is available on the CMS website.

The entire final rule document is available on the Federal Register website.

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