In an effort to ensure that Medicare Advantage and Part D drug programs remain strong, fair and viable, the Centers for Medicare & Medicaid Services (CMS) has ruled on commonsense updates for next year. Some abbreviated highlights:

Medicare Advantage

Guidelines are clarified to ensure equal access to medically necessary care as with Traditional Medicare.

When coverage criteria are not fully established, organizations may create internal coverage criteria based on current evidence in widely used treatment guidelines or clinical literature made publicly available.

To promote more transparent, clinically-based decisions, circumstances are explicitly stated under which plans may apply internal coverage criteria when making medical necessity decisions. 

Part D

Cost-sharing will be eliminated for beneficiaries in the catastrophic phase of coverage.

The Low-Income Subsidy program (LIS) will be expanded.

Plans must not apply the deductible to any Part D-covered insulin product and must charge no more than $35 per month’s supply in the initial coverage phase and the coverage gap phase.

The annual growth in the Base Beneficiary Premium will be capped at 6 percent.

We will continue to provide updates as rulings change that could impact your existing overage or future Medicare decisions.

Source: cms.gov