Effective this year, Medicare Part D plans are now responsible for a significantly larger share—60%—of drug costs in the catastrophic coverage phase (up from 15% in 2023). While this change was intended to reduce out-of-pocket costs for patients, it also gives plans a financial incentive to make it harder for patients to access the treatments they need once they reach the catastrophic phase. We’re already seeing increased use of utilization management (UM) tools—such as step therapy, prior authorization, quantity limits, and formulary changes—that can delay or deny access to essential medications for people with serious conditions like CLL. Although the Centers for Medicare & Medicaid Services (CMS) has stated it is “monitoring” these developments, monitoring alone is not enough. CMS must establish clear rules for the appropriate use of UM tools, require greater transparency from plans, and ensure patients have easy access to this information through tools like the Medicare Plan Finder. Patients deserve timely, appropriate care without unnecessary obstacles. Read the letter to CMS here.
