NCPA Executive Update

NCPA Executive Update delivers insights on legislative, regulatory, policy, and industry developments from NCPA CEO B. Douglas Hoey, Pharmacist, MBA, to NCPA members and pharmacy leaders every other Friday.

Send NCPA your Part D MAC problems | NCPA Executive Update | January 8, 2016

by NCPA | Jan 08, 2016

Dear Colleague,

Doug Hoey

Ten years ago this month, community pharmacies were in total and complete chaos. Ten years ago community pharmacists put the seniors enrolled in the brand new Medicare Part D program on their back and carried them to safety--and simultaneously saved the Part D program from total implosion. Part D has gone on to be baked into government and pharmacy.

Just as predictable are the January problems some seniors have as they switch plans, or plans implement new changes. Every year at this time NCPA's email and phones start to light up with reports from members about problems with prescription drug plans (PDPs) as they try to take care of seniors. This year is no different as we have received numerous reports about MACs being dramatically below acquisition cost on a variety of products, but especially on topicals.

In early 2015, pharmacies were having major issues with Aetna. Patients were walking into the pharmacy of their choice only to find out that their pharmacy was not in the network. Pharmacies that had been told they were in the network when networks were formed in the fall were stunned to find out that was no longer the case.

NCPA intervened and had multiple meetings and calls with officials from the Centers for Medicare & Medicaid Services (CMS). We worked with other pharmacy partners who were receiving similar complaints. CMS listened to these concerns, required Aetna to have a special open enrollment period, and fined the company $1 million as one part of a corrective action plan. In all, CMS estimated that up to 400,000 seniors were affected. The bright spot of the story is that NCPA helped to spur action that corrected the problem.

As mentioned above, the theme so far in 2016 has been absurdly low MAC prices, far below pharmacy acquisition costs. NCPA wants to hear about any problems you are having with Part D so that we can take action with CMS. Of course, on product pricing, your first communication should be to the entity that administers your contract with the plan, usually your PSAO, so it can contact the health plan and try to work out pricing disputes. But after you have reported the problem to your PSAO, make sure that NCPA gets the message so we can also reach out to CMS and/or the health plan.

Also, remember that CMS is now requiring PBMs to update MACs at least every seven days. The first seven-day period of 2016 is today, so keep a watchful eye to make sure MACs are being updated. Based on the complaints we are hearing about the start this year, compliance with the MAC update and disclosure requirements could be put to the test early.

Recall that not all of the provisions made it through CMS' proposed rule from a couple of years ago, but the MAC updates survived. In addition to regular updates, health plans must indicate the source used by the Part D plan for making such updates.

If you are having problems, please use NCPA's template to report them to us by emailing NCPA Attorney's Note: Please DO NOT provide any patient-specific data or personally-identifiable information (name, address, birth date, phone number, insurance ID number, Rx number), from any information you share.

The Part D program has morphed into something very different than how it began 10 years ago. But one thing is the same—community pharmacists have to scrap for every detail to help their patients and hold PDPs to the spirit of the law.


Doug Hoey