CMS Policy Changes to Drug Benefit Program Targets Opioid Abuse

Effective June 15, policy changes for the prescription drug benefit program finalized by the Centers for Medicare & Medicaid (CMS) take effect. CMS published the final rule updating Medicare Advantage (MA) and the prescription drug benefit program (Part D).  The new rule is expected to result in nearly $300 million in annual savings over five years for the Medicare program, which CMS says will result in lower premiums and additional benefits.

One of the more noteworthy changes is the implementation of the Comprehensive Addiction and Recovery Act (CARA) of 2016. This gives new authority for Medicare Part D plans to establish drug management programs effective on or after January 1, 2019. The new rule establishes a framework under which Part D plan sponsors can create a drug management program for beneficiaries at risk for prescription drug abuse or misuse.

Specifically, under drug management programs, Part D plans will engage in case management of potential at-risk beneficiaries by contacting prescribers when the patient is found to be taking a specific dosage of opioids and/or obtaining them from multiple prescribers and multiple pharmacies that may not know about each other. Insurers can then limit at-risk beneficiaries’ access to coverage of controlled substances that CMS determines are “frequently abused drugs” to a selected prescriber(s) and/or network pharmacy(ies) after case management with the prescribers. Part D sponsors cannot implement limitations unless they have engaged in case management with the prescribers, and beneficiaries can submit prescriber and pharmacy preferences.

Beneficiaries who are being treated for active cancer-related pain, are receiving palliative or end-of-life care, or are in hospice or long-term care from drug management programs are exempt.

The rule is in response to the opioid epidemic and is different from a more controversial rule proposed earlier that called for prohibiting automatic refiles of high dose (90 milligrams of morphine per day or more) prescriptions. That proposal resulted in opposition from providers and patients alike. CMS eventually concluded it would have little impact against opioid abuse.

As we have previously written about, there are many ongoing efforts to stem the tide of the opioid epidemic. Last month, Florida’s Attorney General Pam Bondi announced she was filing suit against the nation’s largest opioid drug makers and distributors. She joined AGs in five other states.

And in March, Florida’ Gov. Rick Scott signed tough new legislation that institutes limits on the prescribing of opioids, as well as increases funding for treatment. That legislation takes effect July. 1

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The Health Law Offices of Anthony C. Vitale