- An advocacy group is skeptical of the CMS claim that insurers have few tools to lower the cost of prescription drug prices for drugs that are in protected classes. A report conducted by Avalere Health and commissioned by the Partnership for Part D Access shows Part D plan sponsors are already using a variety of techniques to limit access to expensive medications in protected classes.
- The report found that nearly 75% of all drugs in the six protected classes are placed on a non-preferred or specialty tier — in other words the most difficult drugs to access. It also found there is very low use of these drugs, which are typically the most expensive. "Only 1% of all the prescriptions filled for drugs across the protected classes were for products that are always placed on high tiers," according to the report.
- More than 90% of the prescriptions filled across the protected classes were for generic medications, even though just 35% of the drugs covered are generics, the report found.
Earlier this week, the Trump administration released as part of its ongoing attempt to bring down the cost of prescription drugs a proposed rule that would give Part D plan sponsors more tools, such as step therapy and prior authorization, to manage drugs in the protected classes.
"This study soundly refutes claims that protected classes are driving up costs in the Medicare program because it allows unfettered access to the most expensive medications," said Chuck Ingoglia, senior vice president of public policy and practice improvement at the National Council for Behavioral Health. "In fact, this research shows that plans are aggressively utilizing tier placement and other management tools to drive an overwhelming percent of seniors towards lower cost medications." Ingoglia also serves as executive director for the partnership.
For more than a decade, Part D plan sponsors have had to cover drugs in six protected classes due to concerns over patient access. The protected classes guarantee access to key drugs for conditions like HIV. But those requirements have been a barrier to cutting pharmaceutical costs, CMS Administrator Seema Verma said during a recent conference call.
The proposed rule would allow plans to exclude protected drugs in certain cases, including if a drug manufacturer raised the price of a protected drug beyond a certain threshold. Payers could also exclude a protected class drug that is not a significant innovation over the original product.
But advocacy groups fear that giving plan sponsors more power to limit access could harm patient access to important medications.
"While we have long suspected that plans weren't actually providing access to every medication they are supposed to under the law, we were stunned to see how many of these potentially life-saving drugs aren't being covered at all. CMS should look at this closely," Matthew Cooper, the director of kidney and pancreas transplantation at Medstar Georgetown Transplant Institute, said in a statement.
This summer, the Trump administration unveiled its blueprint to lower drug costs and out-of-pocket expenses for consumers. The plan, known as American Patients First, outlined potential areas to target, and the latest proposed rule sets into motion some of those ideas.