MAPRx Coalition urges Congress and the Centers for Medicare & Medicaid Services (CMS) to take steps to stabilize the Part D market, align plan incentives with beneficiary access, and strengthen transparency.
Specific recommendations include:
- Improve beneficiary-facing transparency about utilization management requirements and real-world access barriers.
- Modernize and simplify the exceptions and appeals process, with public reporting on denials, overturn rates, and timelines.
- Streamline prior authorization for Part D drugs, including timely electronic prior authorization decisions that support continuity of care.
- Expand education and outreach on the Medicare Prescription Payment Plan (MPPP) so beneficiaries understand and can utilize available affordability tools.
- Preserve meaningful standalone prescription drug plan (PDP) choice as the Part D Premium Stabilization Demonstration ends, with transition protections and continuity of care for enrollees facing plan exits or significant premium increases.
- Establish minimum standards for Low-Income Subsidy (LIS) benchmark plan availability and trigger corrective actions when beneficiary choice falls below acceptable thresholds.
- Strengthen CMS oversight of formulary design, cost-sharing structures, and utilization management, including standardized reporting and public disclosure of key access metrics.
- Increase transparency into pharmacy benefit manager (PBM) practices that affect beneficiary access and cost-sharing.
- Base beneficiary cost-sharing on net prices rather than list prices.
- Ensure that the implementation of the out-of-pocket cap, the Medicare Drug Price Negotiation Program, including each initial price applicability year (IPAY), and other elements of the Inflation Reduction Act (IRA) are informed by the experiences and needs of beneficiaries living with chronic diseases and conditions.
- Ensure beneficiaries can reliably obtain drugs with negotiated maximum fair prices (MFPs) at their pharmacy of choice.
These recommendations and supporting evidence are included in this MAPRx Coalition report: Inflation Reduction Act: Access Barriers Undermine Affordability. Specific recommendations and discussion of the MPPP program are included in this MAPRx Coalition report: Reforms Needed: Smoothing the Implementation of the New Medicare Prescription Payment Plan (MPPP) Benefit.
MAPRx will also advocate for:
- Congressional support and funding for the State Health Insurance Assistance Program (SHIP).
- Increased engagement by CMS with patient organizations.
- Permanent Part D coverage of FDA-approved obesity medications.
For additional information on the MAPRx Coalition, please contact Bonnie Hogue Duffy, MAPRx Coalition Convener, at Bonnie@maprxinfo.org or (202) 540-1070.