CMS has published a final rule to update MA and Part D prescription drug benefit program regulations for contract year 2013.  The final rule is summarized after the jump.

Among many other things, the April 12, 2012 final rule:

  • Implements new statutory requirements, including codifying Affordable Care Act (ACA) provisions related to the Medicare Part D Coverage Gap Discount Program and comprehensive medication reviews for beneficiaries in long term care (LTC) settings;
  • Allows CMS to terminate the contracts of MA and Part D plan sponsors that have failed to achieve at least a 3-star rating under CMS’s 5-star rating system for three consecutive years;
  • Requires Part D sponsors to provide beneficiaries with the option of a daily prorated cost-sharing rate for prescriptions for fewer than 30 days under certain circumstances;
  • Requires Part D sponsors to include the prescriber’s NPI on prescription drug event records to enhance CMS efforts to address fraud and abuse;
  • Allows physicians to request Independent Review Entity reconsideration of a denied Part D prescription on their patient’s behalf without a signed authorized representative form;
  • Requires Part D pharmacy benefit managers to report additional financial information; and
  • Allows MA plans to limit coverage of durable medical equipment (DME) to specific manufacturers or brands if certain conditions are met (discussed in greater detail below).

CMS also addressed comments on its suggestion in the proposed rule that LTC facility consultant pharmacists potentially be required to be independent of the LTC facility pharmacy, pharmaceutical manufacturers or distributors, or any affiliate of these entities. CMS is not adopting new policies in this area at this time, but CMS is encouraging the LTC industry to take certain voluntary steps to increase transparency. CMS also is seeking comments on a number of matters relative to a potential future rulemaking to address what CMS considers over-utilization of drugs in the LTC setting; such comments are due June 11, 2012. CMS also has released the CMS 2013 Rate Announcement and Final Call Letter for 2013, which establish updates to payment methodologies, other policies, and program operations for MA organizations and Part D sponsors.