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How the Trump Administration Wants to Change Medicare Drug Rules

On Monday, the Trump administration proposed changes to Medicare’s prescription drug benefit. If passed, changes would take place in 2020.

The aim is to expand choices and lower drug prices by increasing competition, but some of the changes could not be helpful to patients. For example, copays could go down, but premiums are expected to go up.  

Major proposed changes to Medicare Part D and Medicare Advantage rules

Here are the major proposed changes, many based on Trump’s previous “Blueprint” for drug pricing.

  1. Protected class drugs. Insurers will be able to exclude certain drugs from the “protected classes” of drugs (antidepressants, drugs that treat psychosis, anti-seizure meds, cancer drugs, drugs to prevent rejection of a transplanted organ, and HIV-AIDS drugs). Plans can exclude coverage as long as two other similar drugs in the same category are covered, and as long as the drug meets criteria such as having a very high price. Though the goal is to drive prices down, this change could cause major backlash from some patients whose medications are no longer covered.
  2. Out-of-pocket estimates. Doctors and patients will be able to get a more accurate estimate of out-of-pocket costs through new e-prescribing requirements. They will be able to know the drug’s cost at the moment the prescription is written.
  3. Step therapy. Medicare Advantage plans can require step therapy for drugs administered in a doctor’s office. Step therapy means that a patient has to try a lower-cost version of the drug prescribed before trying the drug. Since medications given in a doctor’s office are typically cancer drugs, there will be safeguards in place. Step therapy might also incite opposition in those with cancer and in advocacy groups.
  4. Drug rebates. Patients will pay less for prescriptions due to rebates passed along from drugmakers, saving money for beneficiaries and drug companies alike. This proposal could increase taxpayer costs and premiums, however.

These are only proposals, and wouldn’t take place until 2020. But the proposed changes give doctors, patients, and advocacy groups a lot to ponder.

Andy Slavitt, who was the CMS administrator under President Obama, told The Washington Post: “If this reduces the cost of drugs, that’s good. But if it reduces the availability of drugs or stops covering important drugs, then this is government savings at the expense of patients.”

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