Medicare Taking First Steps to Pharmacy Access
Executive Update from National Community Pharmacists Association (NCPA) CEO B. Douglas Hoey, Pharmacist, MBA

Every year around this time, NCPA starts communicating with members about something known as a "Call Letter." This is a guidance document from the Centers for Medicare & Medicaid Services (CMS) that proposes changes to the Medicare Part D benefit parameters or payment methodology for the coming plan year. CMS has oversight over programs that account for close to half of all the prescriptions in the country so when they speak pharmacy has to listen. CMS' goal is to improve the benefit and help plan sponsors as they prepare their bids for the coming contract year.

The 172-page 2016 Call Letter was released late last Friday, the traditional day and time for what is known in Washington as a "document dump"—when complex or embarrassing government materials are often made public so as to attract less notice. This year's version of the Call Letter clearly is not embarrassing, but it certainly is complex (as usual).

NCPA is still analyzing it in advance of filing formal comments March 6 before it is finalized in early April, but we're pleased with what we've seen so far. CMS has addressed at least to some degree NCPA members' top concerns, according to our 2015 survey. Here are some of the letter's highlights for NCPA members:

1. Enhance transparency into discounted or "preferred" drug copayments. Beneficiaries sometimes find, after enrolling in a plan, that they don't have convenient access to a "preferred" pharmacy that offers the advertised copay. CMS proposes to increase transparency in this area so that beneficiaries can make more informed plan selections. For those plans that do not provide adequate access in certain geographic areas, CMS intends to nudge them to either add more "preferred" pharmacies or restrict marketing the plans in affected areas.

These are welcome first steps and we believe CMS and Congress should go further: Give Medicare beneficiaries access to discounted "preferred" copays at any pharmacy willing to accept the plan's terms and conditions. H.R. 793, now pending in the House, would accomplish this in medically underserved areas.

2. Steer more federal health care dollars to health care services, not PBMs. CMS affirmed that, starting in 2016, plans should provide advance notice to pharmacies how they will be reimbursed for generic drugs and then update those maximum allowable cost (MAC) rates within seven days when prices soar. Currently PBMs may wait months to update reimbursement rates even if a drug's cost shoots up 1,000% or more virtually overnight.

3. Achieve better health outcomes through greater medication adherence. To promote adherence CMS has suggested expanding plans' "star ratings" to include the completion rate for comprehensive medication reviews. CMS will adjust the current $3,138 eligibility threshold for medication therapy management (MTM) services in the final call letter.

4. Improve the appeals process when prescription drug claims are denied. Too often, beneficiaries and community pharmacists encounter denials of prescription drug claims that fail to explain the plan's rationale for rejecting a prescription or how to override or work around it. To smooth and expedite this process, CMS proposes to require plans to provide pharmacies and beneficiaries detailed clinical information about the basis for the denial, the relevant coverage policy and, if applicable, the information needed to cover the medication.

NCPA has prepared a summary of the draft Call Letter. As always, we invite your comments.