Federal Medicare officials have proposed some exciting pro-patient benefits for seniors' Medicare Part D prescription drug plans in 2015. Learn more below and take action now to support implementation of these policies. The Centers for Medicare & Medicaid Services (CMS) is accepting comments on the proposals until March 7th.
Provisions of Medicare's proposed rule offer:
More choice of pharmacy; same co-pay—Rather than limiting seniors to those pharmacies that the drug plan has arbitrarily deemed "preferred pharmacies," the Centers for Medicare & Medicaid Services (CMS) is proposing letting any pharmacy willing to accept a drug plan's terms and conditions (including reimbursement rate) to serve as a preferred pharmacy. Seniors would have greater choice among preferred pharmacies at no added cost. This will particularly benefit seniors in underserved rural areas, where currently the nearest preferred pharmacy may be 20 miles away or more.
Patient choice between community pharmacies and mail order ones—Many seniors don't like mail order facilities and prefer talking to a pharmacist face-to-face. CMS proposes to eliminate some penalties (higher co-pays) for seniors who prefer to use a community pharmacy (many of which provide same-day, home delivery) instead of waiting for the mail. This change is also budget-neutral because CMS research has found that mail order is often more expensive for Medicare and taxpayers than local pharmacies.
More patient access to medication therapy management (MTM) consultations with pharmacists—CMS has proposed expanding coverage of MTM consultations. These in-depth medication reviews have been shown to help improve health outcomes and reduce overall medical costs, by improving adherence to prescribed medication and avoiding costlier treatments, such as hospitalizations.
These new benefits are worthy of support. They are part of a proposed rule, on which CMS is accepting comments through March 7. 2014. Click here to download a sample letter to Medicare that can be personalized and submitted to the agency. To learn how to submit your comments, click here to download instructions.
Families USA: "We believe the proposal to allow any willing pharmacy to participate in the lower cost-sharing will benefit consumers by increasing beneficiary access to pharmacies and reducing beneficiary costs. We also strongly endorse the requirement that pharmacies in a preferred network must consistently charge preferred cost sharing and consistently bill no more than the ceiling price for all prescriptions. Medicare beneficiaries have the right to a system that is predictable and understandable." – Families USA, 2/26/14
"Medicare Rights agrees that local pharmacies willing to match competitors' prices should be allowed to charge the applicable cost sharing." – Medicare Rights Center, 2/26/14
Pharmacy benefit managers (PBMs) foisted "preferred pharmacy" networks and PBM-owned mail order on to the Centers for Medicare & Medicaid Services (CMS) with the promise of grandiose cost savings. In fact, five separate analyses over the past year of Medicare data have shown that preferred pharmacies and/or mail order are often more costly for the program.
Now that Medicare is on to them, those same, discredited PBMs and their supporters appear to be engaged in scare tactics seeking to undermine the agency's proposal.
Here are the facts:
Currently, whether they like it or not, many seniors are steered toward those pharmacies that their drug plan has arbitrarily deemed "preferred pharmacies." The excluded, non-preferred pharmacies are contractually obligated by these drug plans to charge higher co-pays.
CMS is proposing letting any pharmacy willing to accept a drug plan's terms and conditions (including reimbursement rate) to offer "preferred cost-sharing". Seniors would have greater choice among pharmacies at no added cost.
"The proposed Part D rule provisions would increase transparency and increase access to community pharmacy services. Many community pharmacies have been unable to participate in Part D plans "preferred networks" even if they are willing to meet the plans’ preferred prices. CMS proposes to allow any pharmacy who can meet the plan’s prices to participate. This change should increase pharmacy access for patients, particularly in underserved communities where patients may not have access to preferred pharmacies." – Rep. Henry Waxman (D-CA), Ranking Member, U.S. House Energy and Commerce Committee, 2/26/14
"I think it’s outrageous that you have independent community pharmacists that are essentially being locked out of the opportunity to participate in a preferred pharmacy network even when they’re willing to accept the same terms." – Rep. Paul Sarbanes (D-MD), 2/26/14
Rep. Doug Collins (R-GA) wrote to CMS Feb. 24, 2014 that "independent and community pharmacists have dedicated their careers to providing quality patient care, but exclusion from preferred networks has resulted in a strain on their patients and their businesses. I was pleased to see that your agency's proposed rule on Part D included promising language that addresses some of the concerns laid out" in a March 2013 bipartisan letter from Congress.
Rep. Mike Rogers (R-AL) wrote to CMS that "I was encouraged to hear that the proposed rule for Part D dealt with many of the concerns that [community pharmacists] shared with me. Not only were these community pharmacies not allowed to even try and compete with lower co-pays that larger stores can offer, but many seniors signed up for these plans not realizing they would no longer be able to continue using their community pharmacy after signing up."
Medicare's action comes in response to concerns raised in 2013 by approximately 50 members of Congress demanding action. 31 U.S. Representatives wrote: "We are concerned that the allure of cheaper co-pays may drive patients away from their long-time community pharmacist and force them to travel long distances, sometimes across a mountain, to find a pharmacy that is included in a preferred network."
16 U.S. Senators wrote to Medicare: "[W]e ask for additional oversight of Medicare plans with preferred networks."
The debate over whether or not Medicare should negotiate drug costs directly with pharmaceutical makers is outside of the scope of this proposed rule. CMS itself clarified that it interprets the law's intent as to ensure that CMS does not "create any policies or become a participant in any discussions [between plan sponsors and drug makers] that could be expected to interfere" with decisions concerning drug cost, rebate and coverage (or "formulary") issues.
There is no basis for increasing premiums as a result of this policy change. If a community pharmacy is willing to accept the same terms and conditions (including reimbursement level) that PBMs agreed to with a preferred pharmacy, the costs to Medicare and the drug plan are the same.
NCPA op-ed, published in The Hill's Congress Blog.
The Centers for Medicare and Medicaid Services (CMS) proposed Part D rule may sound like typical inside-the-Beltway speak, but it has the potential to dramatically help community pharmacists and their patients.
Among other things, the proposed rule would make long-needed and favorable changes for patients and independent community pharmacists, including:
Stop what you are doing and take action now. Don't put it off. Don't make excuses. Do it today. This might be the most important thing you do for your patients and your business in the next 20 years.
Click here for a toolkit to use in your own communications, which includes a sample letter to the editor, sample social media posts, a sample press release, and sample email pitches to media outlets.
Five separate analyses over the past year of Medicare data have shown that preferred pharmacies and/or mail order are often more costly for the program than non-preferred pharmacies.
Several years into this experiment, we now know that in authorizing preferred pharmacy plans, Medicare officials thought they were trading beneficiaries' pharmacy choice in exchange for cost-savings, but in too many instances they wound up with neither; some of these plans have proven to be MORE expensive to Medicare.
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