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CAPD Comment Letter on CMS-4190-P


Seema Verma, Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention: CMS-4190-P
P.O. Box 8013
Baltimore, MD 21244-8013

Re: Medicare and Medicaid Programs; Contract Year 2021 and 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicaid Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (CMS-4190-P)

Dear Administrator Verma,

Thank you for the opportunity to comment on the Contract Year 2021 and 2022 Policy and Technical Changes to the Medicare Advantage and Medicare Part D Proposed Rule and Request for Information (RFI) that was published in February 2020. The Coalition for Affordable Prescription Drugs (CAPD) represents a broad-based group of employers, unions, health systems, public sector employees, retirees and the pharmacy benefit managers they work with to provide affordable, sustainable prescription drug coverage to their employees and members. CAPD’s members are particularly interested in the changes proposed in this rule that affect how prescription drugs are paid for and managed in federal programs and the subsequent implications for the commercial market.

CAPD strongly supports provisions in the proposed rule to make real-time benefits information available to patients in Medicare Part D plans. As policymakers and plan sponsors work to reduce beneficiary out-of-pocket spending in Medicare Part D and other public programs, real-time benefits programs help patients and their providers choose lower-cost, medically appropriate drugs based on the most up-to-date information about available options. Many of the country’s largest pharmacy benefit managers (PBMs), including OptumRx and CVS Caremark, already offer real-time benefits tools to their clients and plan members and the evidence-based results have meant more savings. Early data from one PBM’s real-time benefits tool shows that physicians have prescribed a different, lower-cost drug about 20% of the time when an alternative was available — and consumers saved on average $80 per prescription fill.[1] This rule builds on previous rules issued by CMS to make real-time benefits information available to Part D beneficiaries and will help improve the program and lower costs for American seniors.

CAPD also supports proposals included in the rule to incorporate Part D plans’ use of generic and biosimilar drugs into CMS Star Ratings. Generic drugs already generate billions of dollars in savings for American patients and the U.S. health care system, producing $293 billion in lower costs in 2018 alone, according to the Association for Affordable Medicines.[2] Biosimilar drugs also stand to offer additional savings to the U.S. health care system by competing with brand biologic drugs, which are some of the most expensive in both Medicare and the commercial market. Incentivizing plans to adopt these drugs when they offer the lowest net cost to patients and plans will help patients save at the pharmacy counter and keep program costs low.

CAPD opposes, however, policies in the proposed rule that target and could potentially limit the use of pharmacy performance measures, which are a central feature of the preferred pharmacy networks that PBMs and Part D plans use to keep drug costs low for beneficiaries. In 2018, 98% of individual Part D plans offered preferred pharmacy networks, encompassing 99% of PDP enrollees.

Previous research by CAPD and Oliver Wyman has shown that preferred pharmacy networks produce significant savings for both beneficiaries and taxpayers. According to the Wyman study, 2018 Part D premiums would have been $72 higher per member per year without the use of preferred pharmacy networks, a 17% increase on the average Part D basic premium.[3] Additionally, federal spending in Medicare would have been $210 higher per member per year without preferred pharmacy networks, thereby increasing the taxpayer burden by $4.5 billion in 2018 alone, and $45.8 billion over the ensuing decade.3

While CAPD and its members welcome federal oversight and collaboration in ensuring that pharmacy performance measures are fairly structured and achieve our shared goals of lowering costs, improving medication adherence and producing better health outcomes, we strongly warn against any measures in the final rule that broadly limit the use of these measures and the preferred pharmacy networks that they underpin.

In addition to the policies outlined in this rule, we encourage CMS to continue to implement provisions that grant PBMs and plan sponsors flexibility to lower beneficiary costs, improve quality of care, and use competition to help lower prescription drug prices throughout federal health programs and the health care system. By building on proven PBM tools, we can ensure that Americans get the prescription medications they need at a cost they can afford.

Debra Barrett

Executive Director

Coalition for Affordable Prescription Drugs

[1] United Healthcare, “No More Surprises at the Pharmacy,” January 16, 2019. Accessible at

[2] Association for Accessible Medicines, “2019 Access and Savings Report.” Accessible at

[3] Oliver Wyman for the Coalition for Affordable Prescription Drugs, “Preferred Pharmacy Networks and Their Impact on Part D Premiums,” March 13, 2018. Accessible at