CMS Rule Reflects ACR’s Advocacy, but More Patient Protections Needed

The Part D Requirement
The same CMS final rule also includes a requirement, effective Jan. 1, 2021, that Part D Explanations of Benefits sent to Medicare beneficiaries include information about drug price increases and lower cost alternatives.

“The ACR agrees that this information is helpful and beneficiaries should have access to any possible ways to lower their out-of-pocket costs,” Angus Worthing, chair of the ACR’s Government Affairs Committee, said in a statement.⁴ “However, we would not support this information being used to force a stable patient to switch to another biologic medication for the sake of cost control. This switch would needlessly disrupt continuity of care and put patients at significant risk [of losing disease control and experiencing] potentially life-threatening complications.”

This is especially true of rheumatology patients, says Dr. Phillips: “The disease control of our rheumatic patients is fragile, and the drug choices we make may be nuanced by patient-specific factors that are not captured in these cost analyses. Moreover, at least until we have access to a wider range of biosimilar options, many of our treatments do not have a cheaper alternative, or the patient may have already passed through and failed one or several of those cheaper alternatives.”

Kelly April Tyrrell writes about health, science and health policy. She lives in Madison, Wis.

References

1. Centers for Medicare & Medicaid Services. Medicare Advantage prior authorization and step therapy for Part B drugs. [Fact sheet.] 2018 Aug 7. https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-prior-authorization-and-step-therapy-part-b-drugs.
2. Centers for Medicare and Medicaid Services. Medicare Advantage and Part D drug pricing final rule (CMS-4180-F). [Fact sheet.] 2019 May 16. https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-and-part-d-drug-pricing-final-rule-cms-4180-f.
3. American College of Rheumatology. American College of Rheumatology Targets Step Therapy and Drug Pricing in New Position Statements. 2019 April 1. https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/1012
4. American College of Rheumatology. American College of Rheumatology statement on CMS Medicare Advantage final rule. 2019 May 20. https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/1019.