1. Are Part D plans required to disclose cost-containment requirements such as step therapy? If so, where?
The MMA Regulations state the following:
§ 423.128 Dissemination of Part D plan information.
(a) Detailed description. A Part D sponsor must disclose the information specified in paragraph (b) of this section in the manner specified by CMS.- (1) To each enrollee of a Part D plan offered by the Part D sponsor under this part; (2) In a clear, accurate, and standardized form; and (3) At the time of enrollment and at least annually thereafter.
(b) Content of Part D plan description. The Part D plan description must include the following information about the qualified prescription drug coverage offered under the Part D plan- (1) Service area. The plan's service area.
(2) Benefits. The benefits offered under the plan, including- (i) Applicable conditions and limitations. (ii) Premiums. (iii) Cost-sharing (such as copayments, deductibles, and coinsurance), and cost-sharing for subsidy eligible individuals. (iv) Any other conditions associated with receipt or use of benefits.
(3) Cost-sharing. A description of how a Part D eligible individual may obtain more information on cost-sharing requirements, including tiered or other copayment levels applicable to each drug (or class of drugs), in accordance with paragraph (d) of this section.
(4) Formulary. Information about the plan's formulary, including- (i) A list of drugs included on the plan's formulary; (ii) The manner in which the formulary (including any tiered formulary structure and utilization management procedures used) functions; (iii) The process for obtaining an exception to a plan's formulary or tiered cost-sharing structure; and (iv) A description of how a Part D eligible individual may obtain additional information on the formulary, in accordance with paragraph (d) of this section. [...]
The text of relevance is in bold. The regulations require the plans to provide this information to enrollees. The regulations do not offer rules about providing this information to the general public.
The Formulary Guidance does not have information about requirements to notify beneficiaries about utilization management tools. The Plan Finder is supposed to have all of the specifics, including utilization management tools, for each drug but it is uncertain if CMS considers this a requirement or if it is just precedent.
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