The six protected classes of drugs under Part D are:
- Anticonvulsants
- Antidepressants
- Antineoplastics
- Antipsychotics
- Antiretrovirals
- Immunosuppressants
Full Answer
What are the six protected classes?
all drugs” within each of the classes. These six protected classes include: anticonvulsants, antidepressants, antineoplastics, antipsychotics, antiretrovirals, and immunosuppressants. The antineoplastics category includes many oral chemotherapy drugs. CMS considered implementing significant changes to the Part D six protected classes in 2014,1 but
What is a protected drug class?
The protected class drugs and some of the ailments they treat include: Anticonvulsants (epilepsy, bipolar disorder, migraine prevention) Antipsychotics (schizophrenia, bipolar disorder, dementia) Immunosuppressants (lupus, rheumatoid arthritis, multiple sclerosis)
What drugs are covered by Part D?
Medicare prescription drug coverage isn’t automatic. Part D covers most prescription medications and some chemotherapy treatments and drugs. If Part B doesn’t cover a cancer drug, your Part D plan may cover it. It’s important to check with your plan to make sure your drugs are on the plan’s formulary (list of covered drugs) and to check ...
Is Medicare covered by Medicare?
Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like copayments, coinsurance, and deductibles.
What are Medicare 6 protected classes?
What are the Six Protected Classes of Drugs?Anticonvulsants.Antidepressants.Antineoplastics.Antipsychotics.Antiretrovirals.Immunosuppressants.
What drugs are protected categories?
These six protected classes include: anticonvulsants, antidepressants, antineoplastics, antipsychotics, antiretrovirals, and immunosuppressants. The antineoplastics category includes many oral chemotherapy drugs.
Is Oncology a protected class?
By halting the change, Medicare Part D plan sponsors participating in the Part D Payment Modernization Model will continue to be required to cover all or substantially all drug therapies in the designated six protected classes, including oncology drugs, once they are approved by the FDA.
Is Medicare Part D voluntary?
Enrollment in Part D is generally voluntary, however, some people are required to enrolled, and others should not enroll. People who have Medicare and who receive assistance under certain federal programs (Medicaid, Medicare Savings Programs, SSI or the Part D Low Income Subsidy) are required to enroll.
What are the antineoplastic drugs?
Antineoplastic drugs are medications used to treat cancer. Other names for antineoplastic drugs are anticancer, chemotherapy, chemo, cytotoxic, or hazardous drugs. These drugs come in many forms, including liquids or pills.
What is the best Part D prescription plan?
Best-rated Medicare Part D providersRankMedicare Part D providerMedicare star rating for Part D plans1Kaiser Permanente4.92UnitedHealthcare (AARP)3.93BlueCross BlueShield (Anthem)3.94Humana3.83 more rows•Mar 16, 2022
What drugs are not covered by Medicare Part D?
Medicare does not cover:Drugs used to treat anorexia, weight loss, or weight gain. ... Fertility drugs.Drugs used for cosmetic purposes or hair growth. ... Drugs that are only for the relief of cold or cough symptoms.Drugs used to treat erectile dysfunction.More items...
Why is Medicare Part D so complicated?
Part D plans have a certain quirk, often called the donut hole or coverage gap, which is important to understand before you purchase one of these plans. In essence, this is a gap in coverage that begins after your plan has spent a certain amount that year, but before you've reached your annual out-of-pocket limit.
What is the CMMI policy?
Earlier this year, the Centers for Medicare & Medicaid Services (CMS) announced a proposed policy by the Center for Medicare and Medicaid Innovation (CMMI) that would have allowed health plans to reduce their coverage of drugs in Medicare’s 6 “protected classes." This policy change could have had negative consequences for patients, including those impacted by cancer. We were concerned that the proposed changes could jeopardize the ability of people with Medicare health coverage to access medications used to manage complex conditions such as cancer, mental illness, HIV-AIDS, epilepsy, Parkinson’s, and organ transplantation.
Does Medicare cover cancer?
People with Medicare health coverage who have cancer need access to all of the medications that will not only treat their cancer but meet their mental health needs and other comorbidities. Individuals diagnosed with cancer are at risk of experiencing depression after diagnosis, which can negatively impact their outcome and the costs of care. A recent CSC study found that:
What problem is this policy meant to address?
Medicare Part D plans (PDPs) are required to cover at least two drugs in each therapeutic class, defined as a group of drugs used to treat the same disease or condition. However, for six therapeutic classes PDPs are required to cover “all or substantially all” drugs.
How could this policy work?
Removing coverage requirements for some or all protected classes may provide PDPs with a greater ability to negotiate rebates when designing a drug benefit compared to their current abilities through utilization management and formulary placement.
What should policymakers consider?
If a protected class designation were removed, plans would gain additional negotiating power only for brandname drugs that could credibly be excluded from formularies under Medicare’s clinical appropriateness criteria.
Endnotes
Centers for Medicare & Medicaid Services, “Medicare Prescription Drug Benefit Manual Chapter 6—Part D Drugs and Formulary Requirements” (2016), https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Part-D-Benefits-Manual-Chapter-6.pdf.
What are the protected classes in Part D?
Current Part D policy requires sponsors to include on their formularies all drugs in six categories or classes: 1) antidepressants; 2) antipsychotics; 3) anticonvulsants; 4) immunosuppressants for treatment of transplant rejection; 5) antiretrovirals; and 6) antineoplastics; except in limited circumstances.
When is the Medicare Advantage and Part D final rule?
Medicare Advantage and Part D Drug Pricing Final Rule (CMS-4180-F) The Centers for Medicare & Medicaid Services (CMS) issued a final rule on May 16, 2019 that modernizes and improves the Medicare Advantage and Part D programs. These changes will ensure that patients have greater transparency into the cost of prescription drugs in Part D ...
When will Medicare Part D be required?
Effective January 1, 2021, CMS will require the Part D Explanation of Benefits that Part D plans send members to include drug price increases and lower cost therapeutic alternatives. This information will inform Medicare beneficiaries about possible ways to lower their out of pocket costs by considering a lower cost medication.
Can you have prior authorization for antiretrovirals?
Under current policy, Part D sponsors are only permitted to impose prior authorization and step therapy requirements for beneficiaries initiating therapy (i.e., new starts) for 5 of the 6 protected classes, with no prior authorization or step therapy allowed for antiretrovirals.
What are the tiers of Medicare?
Here's an example of a Medicare drug plan's tiers (your plan’s tiers may be different): Tier 1—lowest. copayment. An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or prescription drug.
What is a drug plan's list of covered drugs called?
A plan’s list of covered drugs is called a “formulary,” and each plan has its own formulary. Many plans place drugs into different levels, called “tiers,” on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost you less than a drug in a higher tier.
What happens if you don't use a drug on Medicare?
If you use a drug that isn’t on your plan’s drug list, you’ll have to pay full price instead of a copayment or coinsurance, unless you qualify for a formulary exception. All Medicare drug plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally save you money.
How many prescription drugs are covered by Medicare?
Plans include both brand-name prescription drugs and generic drug coverage. The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare drug plans generally must cover at least 2 drugs per ...
What does Medicare Part D cover?
All plans must cover a wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes,” like drugs to treat cancer or HIV/AIDS. A plan’s list of covered drugs is called a “formulary,” and each plan has its own formulary.
How many drugs does Medicare cover?
All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer. The formulary might not include your specific drug. However, in most cases, a similar drug should be available.
What is a tier in prescription drug coverage?
Tiers. To lower costs, many plans offering prescription drug coverage place drugs into different “. tiers. Groups of drugs that have a different cost for each group. Generally, a drug in a lower tier will cost you less than a drug in a higher tier. ” on their formularies. Each plan can divide its tiers in different ways.