Proposed change to CMS Rules Aim Will Expand Access to High-cost Therapies for Medicaid Recipients

August 17, 2020

The Medicaid Best Price rule requires drug manufacturers to give Medicaid the best price on all purchases. However, the rule does not allow for value-based transactions paid on a sliding scale based on therapy efficacy. New CMS rules are being proposed that will allow flexibility for value-based contracting in Medicaid plans, granting low-income patients greater access to high-cost therapies.

“This [proposal] will allow payers and manufacturers to tailor contracts to the chosen product, ensuring that the measures are appropriately matched with the value a therapy can provide. However, the proposed definitions link to a medicine’s actual clinical performance or a reduction in medical expenses and may not encompass the full potential value for the patient,” the National Pharmaceutical Council (NPC) stated.

The NPC further called for more guidance on subscription models and contracts that address combination regimens or cover small numbers of patients. Read more here.

(Source: Mary Caffrey, August 16, 2020)

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