Part D, Medicare Advantage drug plans to install cost-sharing cap by 2025 in new drug price bill


Medicare Advantage and the stand-alone Part D drug plans must implement a maximum monthly cap on patient cost-sharing payments by early 2025, according to the latest version of new legislation. drug price reform.

House Democrats have released legislation for a series of reforms to reduce prescription drug costs, including language on the number of drugs that will be negotiated under insurance. sickness. But the legislation includes key new requirements for payers as Democrats aim to lower drug costs for seniors in Medicare Part D.

The language is expected to be included in a massive $ 1.75 trillion social spending bill being drafted by Democrats that could be passed in Congress in the coming weeks.

An earlier framework for the bill did not include price negotiations and other reforms to the pharmaceutical industry, but Democrats rushed last week to strike a deal that addresses centrist concerns about the damage caused by innovation to industry.

The legislative text establishes a maximum monthly ceiling of co-payment for cost sharing from January 1, 2025.

Any sponsor of Part D prescription drugs and each MAID organization must offer a registrant the option of paying any cost-sharing for plan drugs in monthly capped amounts.

A beneficiary can enroll in the monthly limit option at the start of the plan year or in any month of their plan year.

Insurers must also notify a pharmacy during the plan year when a plan member faces out-of-pocket expenses associated with the option to join the cap.

RELATED: Medicare Advantage Premiums To Decrease Slightly In 2022, Part D To Increase Almost 5%

But language does not prevent an insurer from collecting unpaid sums from a member who does not pay the fees.

The bill also places an annual cap of $ 2,000 on Part D costs starting in 2024. It would also cap co-payments for insulin products of up to $ 35 in Part D. D from the same year.

The legislation confirms that the Department of Health and Human Services will repeal a controversial rule passed by the Trump administration that removes the safe harbor for discounts on Part D drugs, leaving those discounts open to prosecution under the laws. Federal anti-recoil laws. The rule finalized in November 2020 would have created a new safe harbor for discounts offered at points of sale such as the pharmacy counter.

The Biden administration has delayed the implementation date for the rule, and now if the law becomes law, it will be repealed entirely.

Bring drugs to negotiation

Much of the proposal is to give Medicare the power to negotiate the price of certain drugs, but only for less than Democrats initially wanted.

Beginning in 2025, Medicare can choose 10 drugs in Part D or B to negotiate the price. This number increases to 15 drugs in 2026 and 20 drugs in 2028. Drugs must be single-source products and a source of high spending for Medicare.

Any product must also have been on the market for at least seven years before becoming eligible for trading and 10 years for any organic product.

The legislation provides exceptions for certain orphan drugs that treat rare diseases and small biotech drugs, but only from 2025 to 2027.

The bill has already met with major opposition from the pharmaceutical industry even before the text was published.

“Under the guise of ‘negotiation’, this gives the government the power to dictate the value of a drug and leaves many patients with a future with less access to drugs and fewer new treatments,” said Stephen Ubl, group chairman and chief executive officer Pharmaceutical Research and Manufacturers of America, in a statement Tuesday after announcing a deal.

But payers were more supportive of the deal.

“Patients deserve more choices for less,” according to a statement from insurance industry group America’s Health Insurance Plans. “We need to make sure that any changes to Part D hold the big pharmaceutical companies accountable and don’t increase premiums for seniors and patients. “

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