CY 2023 Medicare Advantage and Part D Proposed Rule (CMS-4192-P)-2025

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Starting in 2023, people with Medicare Part D coverage pay no more than $35/month per covered insulin product. This benefit will expand to Part B coverage on July 1, 2023.
The Part D defined standard benefit is changing for 2025 and will include a new $2,000 cap on out-of-pocket drug spending. The benefit will have three phases, including a deductible, an initial coverage phase, and catastrophic coverage.
Starting in January 2025, Medicare Advantage plans will not be allowed to change eligibility criteria in the middle of a plan year. Medicare Advantage plans will be required to use objective criteria when determining whether an enrollee is eligible for SSBCI.
The proposed rule builds on CMS work to remove unnecessary barriers to care resulting from the inappropriate use of prior authorization and internal coverage criteria. The rule would also increase guardrails on the use of artificial intelligence (AI) to protect access to health services.
In 2024, the Part D benefit consists of four phases annual deductible, initial coverage, coverage gap, and catastrophic coverage. CMS will eliminate the coverage gap phase in 2025, further ensuring the end of the donut hole era.
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The Contract Year (CY) 2025 Medicare Advantage and Part D final rule builds on existing CMS policies to promote competition, increase access to care, including important behavioral health services, and protect individuals from inappropriate marketing and prior authorization.

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