The Partnership for Part D Access sent a letter today cosigned by 138 individual patient advocacy organizations to Department of Health and Human Services Secretary-designee the Honorable Xavier Becerra, highlighting the importance of Medicare’s six protected classes policy and urging the Biden administration to reject a late Trump administration proposal to eliminate the benefit
“The protected classes policy has been a cornerstone of Part D’s success: helping to ensure that Part D formularies serve the needs of all Medicare beneficiaries, including the most vulnerable patients with the greatest need for drug coverage,” the letter states. “Accordingly, we implore you to reverse [the Trump administration] policy immediately.”
On January 19, 2021, the Center for Medicare and Medicaid Innovation (CMMI) announced the opportunity for new “formulary flexibilities” for Medicare Part D plans that participate in its Part D Payment Modernization (PDM) Model. Under the proposal, participating plans can choose to limit the drugs they cover, including denying patient access to medications used to manage complex conditions such as cancer, mental illness, HIV/AIDS, epilepsy, Parkinson’s, and organ transplantation.
Partnership: New Report Highlights Access Challenges for Patients with Complex, Chronic Conditions
A new study from the Partnership for Part D Access confirms that the Medicare Part D protected classes policy is an essential pillar of protection for beneficiaries with complex health conditions. Yet, the research also highlights that Medicare prescription drug plans (PDPs) are increasingly limiting access to medications — even for patients with complex, chronic conditions. The study, performed by Avalere Health, a leading strategic advisory company, provides new insights into the various steps Medicare Part D plans are taking to manage utilization of medications covered under Medicare’s six protected classes policy. The protected classes policy is designed to ensure that Medicare beneficiaries with some of the most serious health conditions — cancer, HIV, epilepsy, mental illness, and those at risk of organ rejection, among others — have access to the full range of medicines recommended by their physician.
For Medicare beneficiaries who need a specific medication that their doctor believes is necessary and most appropriate, the six protected classes policy is intended to ensure they can get it. However, even with these protections, this new research demonstrates that patients must often overcome layers of restrictive financial and administrative barriers put in place by plans intended to inhibit access to these essential medications.
According to the Avalere analysis, Part D plans are leveraging formularies and utilization management tools for Medicare beneficiaries across drugs in the protected classes. For example, in 2019, the most recent year for which data is available, plans covered just 54% of drugs across the protected classes — a decrease of nearly 20% since 2016 when the coverage rate was 67%. For covered drugs, nearly two-thirds of all medications in the six protected classes were placed in a non-preferred or specialty category, with 89% of branded products categorized as non-preferred or specialty and 37% of generics also subject to placement on the higher tiers. In aggregate, Part D plans placed drugs from the protected classes on high tiers (non-preferred or specialty) 64% of the time.
These coverage limitations are particularly concerning because of the negative impact they have on patients and their quality of life. If a patient does not receive the best treatment option, it opens the door for complications resulting in emergency department visits, physician visits, hospitalization, or other types of care that increase overall Medicare costs. Moreover, because standalone Part D Prescription Drug Plans (PDPs) are not liable for the cost incurred under Medicare Part A and Part B or Medicaid, research shows that they do not work as hard as commercial plans to ensure they offer a robust formulary. That is why Congress explicitly created fundamental patient protections — including the six protected classes policy — which are unique to Medicare and recognize the unique needs of seniors and persons with disabilities who rely on Medicare.
30 advocacy groups as part the Federal AIDS Policy Partnership (FAPP) are urging Health and Human Services (HHS) Secretary-designee Xavier Becerra to rescind a policy change from the Trump administration that would severely weaken access to life-saving HIV treatments. Their letter echoes a recent flood of complaints triggered by the new Center for Medicare and Medicaid Innovation (CMMI) Part D Payment Modernization (PDM) Model, concluding that impending changes to the Medicare Part D ‘six protected classes’ policy would exacerbate the difficulties experienced by the HIV/ AIDS community.
The letter explains that the six protected class policy has allowed those living with HIV to avoid the burdens of step therapy to access needed medications, as patients often require more complex treatments due to comorbidities and resistance to other antiretrovirals. Stripping away access to these medications would also leave patients vulnerable to discrimination by Part D plan sponsors. Not only is a rollback of these protections harmful to patients, it is also inconsistent with federal HIV treatment guidelines.
“The changes move in the wrong direction for particularly vulnerable Medicare beneficiaries, and in direct opposition to what Congress intended when it established the statutory two drugs per class requirement and the six protected classes,” the letter states. “We again request that you rescind these policy changes to the PDM model.”
Signatories include: AIDS Healthcare Foundation (AHF), AIDS Action Baltimore, AIDS Alabama, AIDS Alliance for Women, Infants, Children, Youth & Families, AIDS Foundation Chicago, AIDS United, American Academy of HIV Medicine, APLA Health, Center for Health Law and Policy Innovation, Community Access National Network (CANN), Community Education Group, Community Research Initiative, Inc. (CRI), Georgia Equality, HealthHIV, HIV+Hepatitis Policy Institute, HIV Dental Alliance, HIV Medicine Association, iHealth, National Alliance of State and Territorial AIDS Directors (NASTAD), NMAC, Positive Health Solutions of the University of Illinois, Positive Women's Network-USA, Prevention Access Campaign, Rural Health Service Providers Network, San Francisco AIDS Foundation, SisterLove, Inc., The AIDS Institute, Vivent Health
The letter can be read here.
Pharmacy Stakeholders to CMMI: Scrap Trump’s Last-Ditch Effort to Weaken Protected Classes
Nine leading pharmacy stakeholder groups penned a letter to the Acting Director of the Center for Medicare and Medicaid Innovation (CMMI) Amy Bassano urging the Biden administration to rescind the Trump administration’s last-minute attempt to weaken Medicare’s six protected classes policy.
The letter calls on the administration to abandon the previous administration’s formulary flexibilities for plans that participate in the Part D Payment Modernization Model, noting that two consecutive administrations have rejected proposals to weaken coverage requirements for drugs in the six protected classes. The organizations also highlight the devastating consequences that these changes would have for minority and underserved populations.
“…Allowing PBMs and Part D plans under the PDM model to opt-out of covering prescribed medications in the six protected drug classes is in direct conflict with President Biden’s Executive Order ‘On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government,’ to ‘pursue a comprehensive approach to advancing equity for all,’” the letter states. “Accordingly, our nation’s pharmacists strongly urge you to remove these provisions in the PDM Model that would effectively strip some of our most vulnerable patients with chronic and mental health conditions from their prescribed medications.”
Signatories include: The American Pharmacists Association (APhA), The American College of Clinical Pharmacy (ACCP), The Accreditation Council for Pharmacy Education (ACPE), The American Society of Consultant Pharmacists (ASCP), The College of Psychiatric and Neurologic Pharmacists (CPNP), The Hematology/Oncology Pharmacy Association (HOPA), The National Alliance of State Pharmacy Associations (NASPA), The National Community Pharmacists Association (NCPA), and The National Pharmaceutical Association (NPhA).
The letter in its entirety can be read here.
Under a dangerous last-minute proposal from the Trump administration, millions of patients may soon lose access to vital medications. Specifically, a proposed demonstration from the Center for Medicare and Medicaid Innovation (CMMI) would allow health plans to sharply scale back their coverage of drugs in Medicare’s six “protected classes” — a policy change that would have devastating consequences for patients. This hasty, deeply misguided program would severely jeopardize Medicare beneficiary access to medications used to manage complex conditions such as cancer, mental illness, HIV-AIDS, epilepsy, Parkinson’s, and organ transplantation.
When Congress designed the Medicare Part D program, it ensured that the full range of medications in the six classes of critically important drugs — antidepressants, immunosuppressants, antipsychotics, antiretrovirals, anticonvulsants and antineoplastics — would be guaranteed on all health plans for the patients who desperately need them. Due to the unique and variable ways in which patients respond to different drugs, it has been widely recognized that doctors need to be provided complete discretion to prescribe the most appropriate medicines for their patients. In short, the six protected classes policy has long stood as a guarantee to patients that their access to all available medications for the most serious diseases would never be in doubt.
In response, the Partnership for Part D Access has launched a national grassroots campaign to urge the Biden administration to swiftly rescind this dangerous program. To support this effort, we encourage you to visit our dedicated comment portal to send a letter encouraging the Biden administration to reverse this proposal. Through this portal, we encourage you to: (1) send our draft comment email directly the Biden administration, (2) incorporate our suggested text into your own message, or (3) draft a message of your own. Letters that you submit will be sent from your email directly to the agency. Letters that you submit will be sent from your email directly to the agency.
Thank you in advance for your help in echoing the broad opposition to weakening Medicare’s six protected classes policy.
Two leading Medicare beneficiary advocacy groups have joined the chorus of stakeholders calling upon the President Joe Biden to take immediate action to rescind the Trump administration’s last-minute attempt to weaken coverage requirements for drugs within the six protected classes policy.
Led by the Medicare Rights Center and the Center for Medicare Advocacy, the letter calls on the administration to rescind formulary flexibilities for plans that participate in the Part D Payment Modernization Model. These changes would allow plan to cover only one drug per therapeutic class, and would drop the requirement for coverage of “all or substantially all” of the drugs in five out of the six protected classes.
In their letter, the organizations cite a June 2020 analysis by Avalere demonstrating that Medicare prescription drug plans are consistently applying utilization management tools to manage spending on prescription drugs within Part D. This analysis is consistent with the Partnership-commissioned Avalere study from 2018 that clearly demonstrates that Medicare’s existing protected classes policy is working as intended for beneficiaries with cancer, HIV, transplant recipients, epilepsy, and mental illness, among others.
“We encourage CMS to rescind the formulary flexibilities it recently extended to plans that participate in the Part D Payment Modernization Model,” the letter states. “As analysis of earlier proposals that relax restrictions requiring plans to cover substantially all medications in the six protected classes shows, these flexibilities are unlikely to significantly drive down costs and may greatly restrict access, above and beyond the impact of utilization management tools.”
The letter in its entirety can be read here.
On their final day in office, the outgoing Trump Administration, through the Centers for Medicare and Medicaid Services (CMS), announced a new proposal that would undermine key patient protections in Medicare's prescription drug program. Indeed, policy outlined in a new Request for Applications (fact sheet) would allow Medicare Part D plans that participate in the third year of the Center for Medicare and Medicaid Innovation’s (CMMI) Part D Payment Modernization (PDM) Model to limit the drugs they cover, including denying patients access medications used to manage complex conditions such as cancer, mental illness, HIV-AIDS, epilepsy, Parkinson’s, and organ transplantation. The Biden Administration will have authority to determine whether the new policy is ultimately implemented.
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