Medicare Does About-Face on 6 Protected Classes

May 29, 2019

Cancer patients are breathing a sigh of relief.  So are patients with movement disorders.  And those with epilepsy, HIV and mental health conditions. 

In a final rule released earlier this month, the Centers for Medicare and Medicaid Services stepped back from a previous proposal to loosen Medicare protections for six classes of drugs that treat complex, high-risk diseases.  The agency instead codified existing coverage policies, ensuring uninterrupted protection – and access – for beneficiaries.

The move came as a tremendous relief to patients.  Historically, Medicare Part D plans have been required to cover substantially all drugs in the six protected classes: anticonvulsants, antidepressants, antineoplastics, antipsychotics, antiretrovirals and immunosuppressants.  A CMS proposal released last year would have removed that coverage requirement, limiting patients’ treatment options within a given class and introducing utilization management tools that can push patients toward the lowest-cost treatment rather than the option that’s best for them.

The proposal was met with outrage from patients and advocates.

“The proposed rule would put new barriers between patients and their medications,” read a comment submitted by the Movement Disorders Policy Coalition.  The Cancer Action Network pointed out that many of the drugs within the six protected classes have no therapeutic equivalent, even within their class.  Given the non-interchangeability of these targeted drugs, removing coverage of certain ones is essentially eliminating treatment for that specific type of cancer.

CMS’s final rule puts that concern to rest.  It also limits prior authorization to patients newly beginning treatment and prohibits step therapy for stable patients.

While the proposed changes – and final rule – would have affected only those with Part D prescription coverage, more than Medicare beneficiaries were anxiously awaiting its release.

“Commercial insurers and state Medicaid programs often follow Medicare’s lead,” said Amanda Talty, CEO of the Tourette Association of America.  “We’re thankful officials reconsidered their proposed approach because limiting access to medications in the six protected classes would have significantly impacted patients’ wellbeing.”

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