By Debjani Mukherjee, Senior Director, Regulatory Affairs, PCMA

In November, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule for the Medicare Parts C and D programs, titled “Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly.” PCMA submitted recommendations on several issues in the proposal for CMS to consider before issuing the final Part C and D rule, with the goal of protecting Medicare beneficiaries from ever-increasing drug prices and improving their experience across their health care journey.

In the letter to CMS, PCMA provided recommendations on codifying policies in the Inflation Reduction Act (IRA). We are seeking guidance regarding utilization management of the drugs CMS sets the price for, improved efficiency in processing the pharmacy transactions for these drugs, and changes to the Medicare Prescription Payment Plan (MPPP). Clear policies lead to a better experience for patients and fewer administrative hurdles for health care providers.

Beyond these statutorily-required provisions, CMS proposed re-interpretation of the statutory meaning of “weight loss drugs” to allow coverage of GLP-1’s for the treatment of obesity as a chronic condition for Part D enrollees. PCMA’s letter argued against this dangerous re-interpretation. Instead, PCMA encouraged CMS to continue allowing plans the flexibility to determine whether to provide coverage of such optional drugs as supplemental benefits.

Additionally, the industry advised against proceeding with unnecessary and duplicative network transparency requirements for pharmacies, which would raise costs without providing additional value. PBMs and their Medicare Part D plan partners value a strong relationship with pharmacies and are committed to helping patients access the drugs they need. Many Part D plans include thousands of pharmacies in their networks, and some include more than 50,000 locations. The information required under the rule is already readily available to pharmacies and additional administrative work would only raise costs for patients.

Read more about the vital role that pharmacies play in creating access to prescription drugs for patients and how PBMs are supporting rural pharmacies HERE.  

As always, PCMA looks forward to continuing to work with CMS on ongoing efforts to improve the Medicare Part D Program.

View PCMA’s full comment letter HERE.

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