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Six protected drug classes could be whittled down to three by 2016
Current Part D rules offer some flexibility in formularies, requiring at least two drugs in 148 categories, but the Centers for Medicare and Medicaid Services (CMS) does not dictate specifically which drugs.
However, drug plan sponsors currently must cover “all” or “substantially all” of the protected drug classes identified by CMS:
• anti-retrovirals; and
• immunosuppressants for the treatment of transplant rejection.
A proposal from CMS would end the protected status for antidepressants and immunosuppresants in 2015, and possibly anti-psychotics in 2016. A recent House Energy and Commerce Committee meeting had both Democrats and Republicans pushing back against the proposal.
It’s not unusual for a patient on an antidepressant to switch drugs within the class to optimize outcomes and reduce side effects, and advocates want patients to have enough choices on formulary to make the necessary switches. Coverage often correlates with treatment adherence for seniors on antidepressants.
Federal officials say ending the protected status of the three drug classes would reduce costs and foster competition. It’s not that CMS is randomly picking classes, rather, CMS proposes to use criteria from the Affordable Care Act that translate to limiting the protected classes to those for which access to all drugs in a class-for a typical patient who needs those drugs-is required within seven days’ time.
Public comment is accepted until March 7, 2014.