PhRMA submits comments on CMS’s Part D specialty tier proposal

Tom Wilbur
Tom Wilbur April 7, 2020

PhRMA submits comments on CMS’s Part D specialty tier proposal.

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Yesterday, PhRMA submitted comments on a Centers for Medicare & Medicaid Services (CMS) proposed rule on policy and technical changes to Medicare Part D and Medicare Advantage.

As part of the proposed rule, CMS is seeking to allow Part D plan sponsors to establish formularies with up to two specialty tiers. If there are two specialty tiers, one must be a “preferred” tier that offers lower cost-sharing than the proposed maximum allowable specialty tier cost sharing. Consistent with CMS’s current policy, beneficiaries would not be able to appeal to access medicines from either specialty tier at preferred tier cost-sharing rates.

For the past decade, PhRMA has expressed concern with the specialty tier and the impacts the policy has on beneficiaries’ ability to access and afford needed medicines that happen to meet the specialty tier criteria. The new proposal for a second specialty tier is a step in the wrong direction for the Part D program.

Below are three key points PhRMA raised in its comments.

  1. The Part D specialty tier creates a large cost-sharing burden for certain beneficiaries, who are prevented from appealing for access to necessary medicines at preferred tier rates.

  2. The Part D specialty tier runs counter to Part D’s non-discrimination requirements.

  3. The implementation of a second specialty tier is likely to result in confusion for beneficiaries and unlikely to improve access or meaningfully reduce program costs.

PhRMA believes that the proposal would make formularies even more complicated and less patient-centered. If CMS is going to proceed with the second specialty tier approach, the proposal must be implemented with appropriate protections for beneficiaries to ensure that none are worse off than under today’s policy. Specifically, CMS should implement the preferred specialty tier with lower cost-sharing than the current specialty tier. Additionally, Part D sponsors should not be permitted to exempt drugs on either specialty tier from the tiering exceptions process altogether.

While PhRMA appreciates the Administration’s efforts to put forward policies that aim to increase competition in the Part D program and reduce out-of-pocket costs for patients, we do not believe a second preferred specialty tier in Part D is the best way to achieve these goals. CMS should be moving away from policies like the specialty tier, which increase costs and barriers to access for beneficiaries, in favor of patient-centered changes that improve access and affordability of medicines.

PhRMA’s full comments are available here.

Learn more about PhRMA’s commitment to solutions that help patients in the Part D program here.

Topics: Part D