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CMS Proposed Rules on Medicare Part D

Preferred Networks and Preferred Cost Sharing (p 1974)
CMS has found that in some cases, sponsors actually charge greater negotiated prices in preferred networks which also may lead to increased costs to the government and taxpayers. This situation also makes beneficiaries make choices that are aligned with plan interests and not the best interest of the Medicare program. CMS also proposes that it eliminate the term “preferred networks” and rather use “preferred cost sharing.” CMS believes that this will eliminate the connotation that some network pharmacies are considered “non-preferred pharmacies” without the opportunity to meet the terms and conditions to qualify for preferred cost sharing.
Any Willing Pharmacy Terms and Conditions (p 1978)

CMS proposes that plans offer a single contract with standard terms for any wiling pharmacy that includes all potential preferred cost combinations and negotiated prices possible for retail settings. This would be a new alternative to current market practice where plans offer different contracts for preferred and non-preferred pharmacies. CMS finds that preferred networks do not always result in consistent savings across medication classes and that some non-preferred pharmacies may offer better rates than network pharmacies. CMS believes a change will level the playing field for small independent community pharmacies.
Mail Order Pharmacy (p 1980)

CMS is concerned that beneficiaries who choose mail order pharmacy may experience unnecessary and extended delays in receiving prescriptions because they must wait between 7-10 days for a regular delivery but if problems occur, then this waiting time could be extended. CMS contrasts this to the experience in the community pharmacy setting where a prescription is presented and filled on the same day and any problems with the prescription are resolved in real time also limiting mail order copay incentives.
Prescription Drug Pricing Standards and Maximum Allowable Cost (MAC) (p 2040)

CMS proposes an updated definition of “prescription drug pricing standard” for purposes of reporting Medicare Part D drug prices to CMS to include MAC prices and other formulas that rely on varying prices and not a fixed, published price. CMS supports plan reporting that allows pharmacies to have current data on the amount of reimbursement expected. MACs would need to be updated at least every 7 days.
Proposed Expansion of MTM and Reduction in Plan Variability (p 1947)

Proposed expansion of the MTM program by reducing the number of multiple chronic diseases eligible for coverage from 4 to 2 and reducing the number of medications required to meet “multiple Part D medications” to 2 or more. CMS proposes lowering the cost threshold from the existing $3,144 to $620.

Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

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