CMS sets higher maximums for cost-sharing under Medicaid

CMS finalized a rule that will allow states to establish higher cost-sharing levels for non-preferred drugs covered by Medicaid. The rule, which will implement provisions of the Affordable Care Act, finalizes the maximum out-of-pocket costs for drugs proposed in a January draft rule. CMS set a maximum of $4 regardless of income level for preferred drugs. For non-preferred drugs, the agency set a maximum of $8 for enrollees with family income levels at or below 150% of the federal poverty level. For enrollees with higher incomes, the out-of-pocket maximum is 20% of the cost of the drug to CMS (see BioCentury Extra, January 15).

CMS received comments on the draft rule noting that "with such high cost sharing differentials, Medicaid enrollees will go without the 'non-preferred' drug even if it is medically necessary and would work far more effectively than a preferred drug." The agency noted that cost sharing is a tool for the states that is permitted under ACA. CMS also noted that the final rule contains a revision that mandates states to allow for "medically necessary" non-preferred drugs to be charged at the preferred rate. ...