CMS Finalizes Policy Changes for Medicare Part D Drug Benefits in 2019: Crackdown on Medicare Payment for Opioids Ahead
Heather Sanderson
April 3, 2018

On April 2, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates Medicare Advantage Plan (MAP) and Medicare Part D policy changes which provides the plans “with new tools to improve quality of care and provide more plan choices for MA and Part D enrollees.” CMS estimates that the changes will result in $295 million in savings a year for the Medicare program over 5 years (2019 through 2023), which will ultimately result in lower premiums. The final rule can be found here.

Noteworthy of the policy change is CMS’ policy changes relative to the Implementation of the Comprehensive Addiction and Recovery Act of 2016 (CARA). CARA requires CMS to establish through regulation a framework that allows Part D Medicare prescription plans to implement drug management programs. Under such programs, the Part D plans can limit at-risk beneficiaries’ access to coverage for frequently abused drugs beginning with the 2019 plan year. CMS will designate opioids and benzodiazepines as frequently abused drugs.

CMS will utilize Drug Management Programs as well as clinical guidelines used to determine if a beneficiary is potentially at-risk, which are based on using opioids from multiple prescribers and/or multiple pharmacies. Part D plans will be allowed to limit an at-risk beneficiary’s access to frequently abused drugs to a selected prescriber(s) and/or pharmacy(ies). CMS will exempt 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.

Commentary: We are pleased to see that CMS has issued this final rule with the goal of managing use of long-term, high-dose opioid and benzodiazepine usage. In 2019 when these rules take effect, we would hope that CMS will apply similar thinking to Workers’ Compensation Medicare Set-Aside (WCMSA) approvals in which the beneficiary is treating with high-dosage opioids. If the Medicare Part D plan would no longer be responsible for paying for the drugs, it should not be included in the WCMSA. Likewise, CMS policy in discouraging long-term, highly-abused opioids should be applied across all CMS policy, including WCMSA policy review.

We will be diving into the issue of WCMSAs and Opioids further in our next Compliance Learning Network webinar live from Bradenton, Florida this week on April 5, 2018 at 1:30 PM EST. We hope you can join us to learn more about this new Final Rule and other recent MSP Updates. Register here.