Proposals Related to: Drug coverage and formularies
Current law and CMS regulations lay out the types of prescription drugs that Part D plans must cover on their formularies. (A formulary is the list of drugs a plan will cover along with its terms for doing so.) For example, plans must cover at least two medications in each drug class that is widely used by Part D beneficiaries and all drugs in six protected classes. The law also enumerates drug classes not covered by Part D, including those to treat anorexia, weight loss, or weight gain. For therapeutic classes that include competing drug products, plan sponsors negotiate price rebates with drug manufacturers in return for placing the manufacturer’s drug on their formulary or on a preferred cost-sharing tier. For high-priced drugs (often biological products), Part D plans may place the drug on a specialty tier in which enrollees must pay coinsurance of 25 percent to 33 percent of the prescription’s price without the ability to appeal for a lower cost-sharing amount. In recent years, manufacturers have launched biosimilar competitors to reference biologics, sometimes at much lower prices. (Biosimilars are biological products that are somewhat analogous to generics, but with some molecular differences from their reference biologics.) For various reasons, Part D plans have been slow to place biosimilars on their formularies. Proposals in this category would change which drugs Part D plans must cover or change the way in which plans may use formulary tools to manage use of prescription drugs.
NOTE: Entries with grey backgrounds are Georgetown estimates. Entries with white backgrounds are either descriptive information or analysis made by or for the proposal authors.
| Proposal | Effects on beneficiaries | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Short description | Category | Author | Federal savings (-$) or costs (+$) | Access to plans | Enrollee costs | Supplemental benefits | Part B premiums | Other affected stakeholders | |
Key:
- Federal savings or costs. When available, we provide original estimates from source materials by the proposal author(s) or from the Congressional Budget Office. Authors prepared estimates for some proposals at a time when plan enrollment and payments differ from today, and thus estimates of savings or costs should be interpreted cautiously. When no author’s estimate was available, Georgetown provided an estimate, as indicated by grey highlighting. Click Details for more information about savings or costs for a specific proposal.
Estimates in source materials prepared by the author(s) cover different numbers of years and windows of time. To give website users a consistent sense of magnitude, we categorized proposals by whether its estimate was approximately less than $10 billion over 5 years or greater than or equal to that amount. Thus, in this column,- +$ indicates anticipated costs to the federal government of less than $10 billion over 5 years.
- +$$ indicates anticipated costs of $10 billion or more over 5 years.
- –$ indicates anticipated savings to the federal government of less than $10 billion over 5 years.
- –$$ indicates anticipated savings of $10 billion or more over 5 years.
- We list a question mark for proposals in which the author(s) would need to specify more detail to estimate federal spending.
- Effects on beneficiaries. When available, the estimate was provided by the proposal author(s) within the cited source materials. When no author’s estimate was available, Georgetown provided an estimate, as indicated by grey highlighting. In the four columns under this header,
- Up arrows indicate anticipated greater access to plans, higher costs (premiums and cost sharing) for plan enrollees, more availability of extra benefits, or higher Part B premiums applicable to all beneficiaries.
- Down arrows indicate the reverse effects.
- Combined up and down arrows indicate mixed effects, such as up for some categories of beneficiaries and down for others.
- Categories may also be reported as “minimal or no effect” or “not applicable.”
- We list a question mark for proposals in which the author(s) would need to specify more detail to estimate effects on beneficiaries.
- Click Details for more information about beneficiary effects for a specific proposal.
- Other affected stakeholders. This column reports any stakeholders other than Medicare beneficiaries likely to be affected significantly by the proposal. Click Details for more information about a specific proposal.