The Centers for Medicare & Medicaid Services issued its contract year 2025 Medicare Advantage and Part D final rule, with provisions effective on June 3, 2024. Important provisions are discussed below.
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Expanding Medication Therapy Management. CMS finalized changes to Medicare Part D MTM eligibility criteria to: (1) add HIV/AIDS to the list of core chronic diseases, requiring plan sponsors to include all 10 core chronic diseases identified by CMS in their targeting criteria; (2) require plan sponsors to include all Part D maintenance drugs and expressly state that Part D sponsors retain the flexibility to include all Part D drugs in their targeting criteria; and (3) revise the methodology for calculating the MTM cost threshold to be commensurate with the average annual cost of eight generic drugs (set at $1,623 for CY 2025). CMS is not finalizing the proposal to reduce the maximum number of drugs a plan sponsor may require for targeting enrollees taking multiple Part D drugs and is retaining the maximum number of drugs as eight drugs. NCPA supported increased application of MTM in our comments to the proposed rule.
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Biosimilars. CMS finalized two changes to provide Part D sponsors with more flexibility to make midyear substitutions of biosimilars for their reference products on their formularies.
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Anti-steering provisions. CMS also finalized protections against Medicare Part D and MA health plan patient steering. Specifically, CMS set requirements that redefine “compensation” to set a clear, fixed amount that plans can pay their agents and brokers regardless of the plan the individual enrolls in, addressing loopholes that result in commissions above this amount that create anti-competitive and anti-consumer steering incentives. Additionally, the final rule generally prohibits contract terms between Medicare Advantage organizations/Part D sponsors and middleman Third Party Marketing Organizations, such as field marketing organizations, that may directly or indirectly create an incentive to inhibit an agent’s or broker’s ability to objectively assess and recommend the plan that is best suited to a potential enrollee’s needs.
For additional details, see the CMS fact sheet, press release, and final rule. The rule is scheduled to publish in the Federal Register on April 23.
