DIR fees are knocking down pharmacy profits
|
|
- Monica Marilynn McLaughlin
- 5 years ago
- Views:
Transcription
1 16 America s PHARMACIST November 2016
2 DIR fees are knocking down pharmacy profits by Bruce A. Semingson, Pharmacist In 2016, retail pharmacy will pay between $360 million and $2.16 billion in direct and indirect remuneration (DIR) fees to Medicare Part D plans, according to my calculations as outlined in Table 1. In the majority of cases these fees have been paid to participate in various preferred or narrow pharmacy networks established by the plan. Today, industry sources and pharmacy blogs estimate that flat DIR fees range from $2 to more than $7.50 per prescription and may also be assessed as a percentage, thus having greater variability. (See reference 1 at end of article.) These fees are lowering gross profits for retail pharmacies more than ever before. Editor s Note: This is the first of a two-part series. 17
3 Prescription DIR fees emerged in 2012 when Humana and Walmart launched the first Medicare Part D Preferred Network. Patients utilizing Walmart pharmacies paid copayments which were up to $9 less or coinsurance up to 17 percent less than those available at other Humana network pharmacies. (See Table 1.) The use of DIR fees has a greater positive impact on sponsor profitability than deeper reimbursement discounts paid to pharmacies. DIR BROADLY DEFINED DIR, defined by the Centers for Medicare & Medicaid Services (42 C.F.R ), consists of any and all rebates, subsidies or other price concessions from any source including manufacturers, pharmacies, enrollees, or any other person that serves to decrease the costs incurred by the Part D sponsor (whether directly or indirectly) for Part D drugs. The DIR includes discounts, chargebacks, rebates, cash discounts, free goods contingent on a purchase agreement, upfront payments, and coupons. The CMS definition also states price concessions that are not considered to directly or indirectly impact drug costs incurred by the Part D sponsor are not included in DIRs. Following the introduction and subsequent evaluation of the success of the Humana-Walmart preferred network, other prescription drug plans added preferred networks, leading to today s saturation point. It is estimated that 75 percent of Part D enrollees have access to a preferred network. (See reference 2 at end of article.) According to Adam J. Fein, PhD, author of the Drug Channels blog, 62 Medicare Part D plans have preferred or narrow networks representing 754 regional PDPs. Enrollment in these 62 plans totaled 14.9 million people, or 75 percent of the PDP total through Dec. 4, CMS prefers to label preferred networks Preferred Cost Sharing Networks. Enrollees in these networks have lower out-of-pocket costs (copayments, coinsurance) than are available at other non-preferred network pharmacies enrolled in the plan s pharmacy network. Cost sharing in for low income subsidy patients is limited by law and they are less likely to be influenced by plan design such as preferred networks. (See Table 2.) However, pharmacies enrolled in a preferred network pay DIR fees for all claims dispensed. DIR fees are paid by participating pharmacies to the plan sponsor or its affiliated PBM. Plan sponsors consider the DIR fee a cost control method as it is outside the adjudication process. The plan sponsor can utilize these fees to modify patient benefits, reduce patient out-of-pocket costs or premiums, and to enhance a plan s profitability. DIR fees are reportable to CMS after the close of each plan year. They are not identified or reported at the point of sale. (NCPA has urged CMS to require plans to estimate DIR fees at point of sale.) REIMBURSEMENT UNCERTAINTIES From a retail pharmacy perspective, the total reimbursement, when a DIR fee is applied, is the adjudicated rate (calculated product reimbursement plus dispensing fee or maximum allowable cost plus dispensing fee etc.) minus the DIR. As DIR fees are invoiced by the plan to the pharmacy months after claims are adjudicated, a pharmacy will not know the total reimbursement (or gross profit) until Table 1. First Part D Preferred Network Cost Sharing Design Walmart PN Non-Preferred Network Mail Order Tier 1 Preferred Generics Tier 2 Non-Preferred Generics Tier 3 Preferred Brands Tier 4 Non-Preferred Brands $1 Copay $10 Copay $0 $5 Copay $12 Copay $0 20% Coinsurance 37% Coinsurance 20% 35% Coinsurance 40% Coinsurance 35% Source: 2012 Summary of Benefits. Humana Walmart Preferred Rx Plan (PDP). North Carolina Department of Insurance America s PHARMACIST November 2016
4 many months in the future. By law, the Medicare program is prohibited from becoming involved in negotiations among plan sponsors and pharmacies. The use of DIR fees has a greater positive impact on sponsor profitability than deeper reimbursement discounts paid to pharmacies. DIR fees reduce the cost of patient benefits, such as out-of-pocket costs, which are reflected in the PDP premium. A lower premium is more competitive, increasing the opportunity of an increase in enrollment and ultimately increased profitability. It is logical, then, that the use of DIR fees has resulted in a significant decrease in profitability for retail pharmacies. As DIR fees are outside of the adjudication process, they are not visible to beneficiaries, other Medicare Part D plans, or pharmacy competitors. DIR fees are assessed by various methods, typically either a flat fee for every prescription dispensed to plan patients, or a percentage of ingredient costs, and may be further adjusted based on performance metrics. DIR fees linked to performance metrics established by CMS for Part D plan star ratings may be even more onerous for pharmacies that do not meet performance benchmarks. CMS has quality measurement programs to reward physicians and hospitals and other providers when they meet defined performance measures, and it rewards Medicare Advantage Prescription Drug Plans (MAPDs, aka Part C) and PDPs when defined performance measures are realized. Unfortunately, the linking of star measures with pharmacy DIR fees is a deviation from the intent of the Medicare Part D Star Ratings Program 19
5 are five pharmacy-specific measurers: high-risk medications (HRM); medication adherence for diabetes medications; medication adherence for hypertension (RAS antagonists); medication adherence for cholesterol (statins); and MTM program completion rates for comprehensive medication reviews (CMRs). A plan with the highest rating, 5 stars, enjoys certain marketing and financial rewards such as year-round enrollment. PDPs and MAPDs with low star ratings have restrictions and may be terminated by CMS. Plan ratings are included in the Medicare Plan Finder website ( and from the accepted definition of the word performance. Imagine, as an employer, your top performing employees are rewarded by reducing their compensation. UNDERSTANDING THE PART D BIDDING PROCESS It is critical for retail pharmacies and/ or their pharmacy services administrative organizations to understand the CMS Part D bidding process for plan sponsors relating to medication therapy management (MTM) services and star ratings, because retail pharmacies are being measured on some of these performance metrics. For the 2016 plan year, CMS utilizes 32 measures to determine a Star Rating for Medicare Part C plans and 15 measures for Part D plans. Included All PDPs and MAPDs submit annual bids to CMS seeking continuation or admission to participate in the subsequent year s annual enrollment of Medicare eligible patients. The bids are complex and include a description of the patient benefits, patient out-of-pocket costs, drugs included in the formularies, monthly premiums, pharmacy networks, service areas, and more. Table 2. Estimated Total DIR/Access Fees Industry experts estimated that people 65 years of age and older take from 2 to over 6 prescription drugs on a regular basis. An estimated 15 million people are enrolled in PDPs with preferred networks as of December Following is a calculation of annual DIR/access fees assuming that only 50% of the 15 million enrollees utilized a PN. Number of enrollees Est. % utilizing PN Average # prescriptions per month # Annual prescriptions DIR/Access Fee Est. total annual fees 15,000,000 50% 2 24 $2.00 $360,000,000 15,000,000 50% 2 24 $4.00 $720,000,000 15,000,000 50% 4 48 $2.00 $720,000,000 15,000,000 50% 4 48 $4.00 $1,440,000,000 15,000,000 50% 6 72 $2.00 $1,080,000,000 15,000,000 50% 6 72 $4.00 $2,160,000,000 Notation: As of Dec. 4, 2015, Drug Channels reported 19.9 million enrollees in the 10 largest PDPs with preferred pharmacy networks. A total of 14.9 million have access to a preferred network. Sources: Medicare Part D Contract and Enrollment Data, Centers for Medicare and Medicaid Services, June 18, Medicare Part D 2016, 75% of Seniors in a Preferred Pharmacy Network, Drug Channels, Jan. 20, America s PHARMACIST November 2016
6 PART D OFTEN TIED TO DIR FEES Today many Part D Plans utilize one or more of the pharmacy quality measures in the Medicare Part D Star Ratings Program to rate the pharmacy performance level versus their peers. The performance level is often tied to DIR fees for participation in the plan s performance network. Below is a hypothetical example: Assume that a plan applies the medication adherence for cholesterol measure in order to create a tiered assessment of DIR fees. In this example, if a pharmacy achieves a Tier 1 score during the measurement period (usually a calendar quarter), it will be invoiced the corresponding fee, in arrears, for every prescription dispensed to plan members during the measurement period. It has been reported that some Medicare plans utilize generic dispensing rates to determine DIR fees. Several other entities have emerged that specialize in reporting pharmacy quality measures, such as adherence and HRM use. These entities include PQA s EQuiPP, imedicare, Prescribe- Wellness, Ateb, Mevesi, Rx30, Q/S1's engage, and PioneerRx. While the example described earlier is hypothetical, pharmacy owners can apply similar logic to determine their performance level and future DIR fees. It is critical to project the future DIR fee costs to have the cash available for payment. Follow these steps: 1. Identify contracted Part D plans with applicable DIR fees. Tier Statin adherence score DIR fee per prescription 1 85% or greater $ % $3 3 70% or less $4
7 Many questions remain regarding the use of DIR fees. The following are some of most prominent. 1. Will CMS review PDP and MAPD conditions of use of DIR fees, accountability and transparency? 2. Do these DIR fees conform to CMS regulations which require that they lower patient out-of-pocket costs and/or premiums? 3. CMS currently permits the collection of DIR fees and they are reported to CMS at the end of each plan year. Will CMS audit the disbursement of these fees? Bills That Would Ban Retroactive DIRs in Part D Pending in Congress NCPA will be urging Congress, which is expected to hold a post-election lame duck session this month, not to adjourn before acting on legislation that would prohibit retroactive direct and indirect remuneration pharmacy fees on clean claims in Medicare Part D. Through NCPA advocacy efforts, bills to do so have been introduced in both the Senate and the House. Cosponsors were added thanks to the thousands of s NCPA members have sent to congressional offices. S has nine signed Senate supporters and H.R has 24 in the House. The identical measures are backed by nearly 100 pharmacy stakeholder organizations including 40 state pharmacy associations, wholesalers, grocery stores, buying groups, and regional chain pharmacies, along with independent community pharmacies and franchisees. The bipartisan bills are titled the Improving Transparency and Accuracy in Medicare Part D Spending Act. At last month s NCPA Annual Convention, the House of Delegates adopted a resolution strongly endorsing legislation to ban postdispensing DIR fees in Part D. Since the advent of Medicare Part D, pharmacists have demonstrated their commitment to its success. They invested an incalculable amount of time and resources educating patients about the program and how to select Part D plans that met their needs (a process that continues to this day). They endorsed and supported various MTM programs, often at a financial loss, and they implemented compliance and adherence programs which support CMS initiatives and patient well-being. Now, contract terms require pharmacies to pay DIR fees if they desire to participate in a preferred network. Absence from a preferred network may lead to the loss of patients. Patients select pharmacists based on many factors, but most importantly because they respect and trust them to take care of their health needs. a. Determine the performance metrics and fee tiers. 2. Identify your patients in these plans. 3. Track your pharmacy performance metrics, by plan, utilizing one of the available service entities identified previously. Contact your pharmacy dispensing system entity to assist you. 4. Once your performance tier is determined, multiply the number of the dispensed prescriptions for patients in the plan in the measurement period times a DIR fee. This total is your estimated account payable for this plan. 5. Your contract will define the settlement terms of this payable 6. Contact your PSAO to determine fee calculation methodology and settlement terms. Retail pharmacies, as well as all health care providers, are experiencing major changes in the delivery of health care services to patients. CMS, insurers, and health plans are attempting to transition the delivery of health care from a system based on a fee-for-service aka quantity payment system, to one based on quality and outcomes. In pharmacy, this transition is changing the business model from one based 22 America s PHARMACIST November 2016
8 solely on margins and profits derived from the dispensing of prescription drugs to one where dispensing margins are close to acquisition costs and pharmacists are paid for patient care services and performance. During this transition, plans/payers have the obligation to structure payments methodology for prescription drugs in a clear and transparent manner. In addition, plans and payers must structure performance programs to reward high performing pharmacies that excel in patient services and outcomes. Partnerships between plans, pharmacists, physicians, hospitals, and manufacturers would be ideal. Pay-for-performance is emerging, which will be discussed in my next article Pharmacy based Pay for Performance Programs: Improving Patient Health Care, in the December 2016 issue of America s Pharmacist. Bruce A. Semingson, Pharmacist, is president of Pharmacy Perspectives, LLC, Cave Creek, Ariz. He can be reached at bruce.semingson@gmail.com. References 1. Pharmacies Face Financial Harships with Rising DIR Fees, Pharmacy Times, July 28, 2016; Rising Fees Pinch Some Pharmacies, Wall Street Journal, Nov. 3, 2015, page B8; Pharmacy Development Services, Blog, July 18, 2016; Community Pharmacists cite problems with DIR fees, NCPA, June Medicare Part D Contract and Enrollment Data, Centers for Medicare and Medicaid Services, June 18, Medicare Part D 2016, 75% of Seniors in a Preferred Pharmacy Network, Drug Channels, Jan. 20, 2016.
Implement a definition of negotiated price to include all pharmacy price concessions.
NCPA Analysis of Medicare Part D Pharmacy DIR Fee Reform Policy Proposal and Other Policies Impacting Community Pharmacies in the CMS Proposed Rule, Modernizing Part D and Medicare Advantage to Lower Drug
More informationDIR FEES: WHAT YOU NEED TO KNOW JULY 13, :00 10:00 AM
DIR FEES: WHAT YOU NEED TO KNOW JULY 13, 2017 9:00 10:00 AM ACPE UAN: 0107-9999-17-078-L04-P 0.1 CEU/1.0 hr Activity Type: Knowledge-Based Learning Objectives for Pharmacists: Upon completion of this CPE
More informationHow Medication Adherence and Outcomes Are Changing the Business Model
How Medication Adherence and Outcomes Are Changing the Business Model Laura Cranston Executive Director Todd Sega Manager, Payer Relations Lari Harding VP, Strategy & Growth Healthcare Network 3 Session
More informationUnderstanding Pay For Performance and DIR Impact to Pharmacy Reimbursement
Understanding Pay For and DIR Impact to Pharmacy Reimbursement A Public Service Announcement brought to you by Melanie Maxwell, MHP Vice President RxSelect Pharmacy Services Please Don t Shoot the Messenger
More informationDIR: Trends, Issues, and Impending Impacts
DIR: Trends, Issues, and Impending Impacts Lari Harding Vice President, Product Marketing Chris Smith, R.Ph Director, Pharmacy Business Intelligence 1 Disclosures Lari Harding is the Vice President, Product
More informationSurvey Analysis of January 2014 CMS Medicare Part D Proposed Rule
Survey Analysis of January 2014 CMS Medicare Part D Proposed Rule Prepared for: Pharmaceutical Care Management Association Prepared by: Stephen J. Kaczmarek, FSA, MAAA Principal and Consulting Actuary
More informationImpact of H.R. 1038/S. 413 on CMS Payments Under Part D
At the request of the (NCPA), Wakely Consulting Group, LLC (Wakely) has estimated the financial impact of companion House and Senate bills H.R. 1038/S. 413 ( Improving Transparency and Accuracy in Medicare
More informationSTAR RATINGS PBM PARTNERSHIP, MAXIMUM RESULTS. Michelle Juhanson, CHC, CHPC Director of Compliance and Quality PerformRx
STAR RATINGS PBM PARTNERSHIP, MAXIMUM RESULTS Michelle Juhanson, CHC, CHPC Director of Compliance and Quality PerformRx Agenda History & Timeline Quality Bonus Payment CMS Changes The PBM Role Best Practices
More informationPresented January 20 th by Pharmacy Healthcare Solu7ons, Inc. Don Dietz, R.Ph, MS, Vice President
Presented January 20 th by Pharmacy Healthcare Solu7ons, Inc. Don Dietz, R.Ph, MS, Vice President Disclosures Don Dietz is an employee of Pharmacy Healthcare Solu0ons, Inc. The conflict of interest was
More informationThe Impact of Adherence Quality Measures on the US Healthcare Marketplace
The Impact of Adherence Quality Measures on the US Healthcare Marketplace Samuel Stolpe, PharmD Associate Director, Quality Initiatives Pharmacy Quality Alliance Pharmacy Quality Alliance (PQA) Established
More informationFarm Bureau Select Rx 2017 Summary of Benefits January 1, December 31, 2017
P.O. Box 266380 Weston, FL 33326 Farm Bureau Select Rx 2017 Summary of Benefits January 1, 2017 - December 31, 2017 Thank you for your interest in Farm Bureau Select Rx, Our plan is offered by Members
More information(PDP) 2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)
(PDP) 2014 Summary of benefits for our prescription drug plans (Enhanced and Standard) Contract S5540, Plans 004 and 002 January 1, 2014 December 31, 2014 U5073c, 8/13 Y0079_6249 CMS Accepted 09112013
More informationHow you are being measured by health plans, PBMs and accreditation organizations. December 2013
How you are being measured by health plans, PBMs and accreditation organizations December 2013 1 The U.S. health care system is rapidly moving to valuebased purchasing or value-driven healthcare Value
More informationFarm Bureau Essential Rx 2018 Summary of Benefits January 1, December 31, 2018
Farm Bureau Health Plans P.O. Box 266380 Weston, FL 33326 Farm Bureau Essential Rx 2018 Summary of Benefits January 1, 2018 - December 31, 2018 Thank you for your interest in Farm Bureau Essential Rx.
More informationAugust 4, The Honorable Charles Rangel, Chairman Committee on Ways and Means United States House of Representatives Washington, D.C.
August 4, 2009 The Honorable Charles Rangel, Chairman Committee on Ways and Means United States House of Representatives Washington, D.C. 20515 The Honorable Henry A. Waxman, Chairman Committee on Energy
More informationThe Impact of the Medicare Prescription Drug Legislation on Pharmaceutical Revenues
The Impact of the Medicare Prescription Drug Legislation on Pharmaceutical Revenues Presented By: Jack Rodgers PricewaterhouseCoopers February 27, 2004 P w C Overview of Recent Medicare Act On December
More informationPart D: The New Medicare Prescription Drug Law Implications for Medicaid
Part D: The New Medicare Prescription Drug Law Implications for Medicaid Vernon K. Smith, Ph.D. HEALTH MANAGEMENT ASSOCIATES For State Coverage Initiatives National Meeting Washington, D.C. February 4,
More informationMEDICARE PLAN PAYMENT GROUP
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 MEDICARE PLAN PAYMENT GROUP Date: May 30, 2018 To: From: All Part D
More information2015 PacificSource Medicare Part D Transition Process for contracts H3864 & H4754:
2015 PacificSource Medicare Part D Transition Process for contracts H3864 & H4754: Essentials Rx 6 (HMO), Essentials Rx 14 (HMO), Essentials Rx 15 (HMO), Essentials Rx 16 (HMO), Essentials Rx 19 (HMO),
More informationManufacturer Patient Support Initiatives: Current Practices and Recent Challenges. Andrew Ruskin Morgan Lewis
Intersecting Worlds of Drug, Device, Biologics and Health Law AHLA/FDLI May 22, 2012 Manufacturer Patient Support Initiatives: Current Practices and Recent Challenges by Andrew Ruskin Morgan Lewis The
More informationFollow the Dollar / Understanding Drug Prices and Beneficiary Costs Under Medicare Part D
Follow the Dollar / Understanding Drug Prices and Beneficiary Costs Under Medicare Part D Prepared for: The National Pharmaceutical Council Prepared by: Avalere Health LLC Lindy Hinman John Richardson
More informationMartin s Point Generations Advantage Policy and Procedure Form
Martin s Point Generations Advantage Policy and Procedure Form Policy #: PartD.923 Effective Date: 4/16/10 Policy Title: Part D Transition Policy Section of Manual: Medicare Prescription Drug Benefit Manual
More informationsummary of benefits Blue Shield of California Medicare Rx Plan (PDP)
summary of benefits Blue Shield of California Medicare Rx Plan (PDP) An employer-sponsored Medicare Prescription Drug Plan for City and County of San Francisco retirees, spouses and eligible dependents
More informationI. PURPOSE. A. The primary objectives of Molina Healthcare s Transition Policy and Procedure are:
I. PURPOSE The purpose of the Policy and Procedure is to ensure necessary continuity of treatment and to provide adequate time and transition process to introduce the enrollee and their prescribing physician
More informationTestimony of Mark Merritt. Pharmaceutical Care Management Association
Testimony of Mark Merritt Pharmaceutical Care Management Association Before the UNITED STATES SENATE COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS The Cost of Prescription Drugs: How the Drug Delivery
More informationPrescription Drug Pricing and Community Pharmacy NALEO Legislative Summit on Health October 21, 2017
Prescription Drug Pricing and Community Pharmacy NALEO Legislative Summit on Health October 21, 2017 Ronna Hauser, PharmD VP Pharmacy Affairs The strength of our numbers NCPA represents America's 22,000+
More informationCommunity Care, Inc. Medicare Part-D Enrollee Transition Plans H5212 PACE and H2034 HMO-SNP 2018
Title: and H2034 HMO-SNP 2018 Policy Identifier: PA - Pharmacy Effective Date: 20180101 Scope: Organization Wide Family Care PACE Partnership Waukesha Day Center HUD (Housing and Urban Development) Department:
More informationAn Overview of the Medicare Part D Prescription Drug Benefit
October 2018 Fact Sheet An Overview of the Medicare Part D Prescription Drug Benefit Medicare Part D is a voluntary outpatient prescription drug benefit for people with Medicare, provided through private
More informationINDUSTRY TRENDS IN PHARMACY REIMBURSEMENT
INDUSTRY TRENDS IN PHARMACY REIMBURSEMENT Heather Shouse, Sr. Director, Healthcare Solutions/ Inmar Jon Brumbaugh, Sr. Manager, Product, Healthcare / Inmar Disclosure We have no relationships with commercial
More information2019 Transition Policy and Procedure
2019 Transition Policy and Procedure POLICY Steward Health Choice Generations (SHCG) provides a Part D drug transition process in order to prevent enrollee medication coverage gaps. SHCG s transition process
More informationSummary of Benefits for Blue MedicareRx Standard SM (PDP), Blue MedicareRx Plus SM (PDP) and Blue MedicareRx Premier SM (PDP)
Summary of Benefits for Standard SM (PDP), Plus SM (PDP) and Premier SM (PDP) Available in Colorado A -approved Part D sponsor. Anthem Insurance Companies, Inc. (AICI) has contracted with the Centers for
More informationMedicare Part D Transition Policy CY 2018 HCSC Medicare Part D
Contract: H0107, H0927, H1666, H3251, H3822, H3979, H8133, H8634, H8554, S5715 Policy Name: Medicare Formulary Transition Purpose: This procedure describes the standard process Health Care Service Corporation
More informationSupport and pass provider status legislation in the House and Senate (H.R. 592/S. 109).
ISSUES Preserve beneficiary access to pharmacy services provided to Medicaid, Medicare and commercially-insured patients as Congress continues to debate health care policy. Support and pass provider status
More information2012 Medicare Part D Transition Process for contracts H3864 & H4754:
2012 Medicare Part D Transition Process for contracts H3864 & H4754: Essentials Rx 6, Essentials Rx 14, Essentials Rx 15, Essentials Rx 16, Premier Rx 7, Explorer Rx 1, Explorer Rx 2, and Explorer Rx 4
More informationMEDICARE PLAN PAYMENT GROUP
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 MEDICARE PLAN PAYMENT GROUP Date: June 23, 2017 To: From: All Part
More informationKEEPING PRESCRIPTION DRUGS AFFORDABLE: The Value of Pharmacy Benefit Managers (PBMs)
The Texas Association of Health Plans Representing health insurers, health maintenance organizations, and other related health care entities operating in Texas. KEEPING PRESCRIPTION DRUGS AFFORDABLE: The
More informationApril 8, 2019 VIA Electronic Filing:
April 8, 2019 VIA Electronic Filing: http://www.regulations.gov The Honorable Alex Azar Secretary Department of Health and Human Services 200 Independence Avenue SW, Room 600E Washington, D.C. 20201 Re:
More informationPACE & Medicare Part D
PACE & Medicare Part D www.npaonline.org Shawn Bloom National PACE Association Shawnb@npaonline.org (703) 535-1518 PACE & Part D Session Objectives PACE Medication Regulations What Does Part D Cover What
More informationBERKELEY RESEARCH GROUP. Executive Summary
Executive Summary Within the U.S. healthcare system, the flow of dollars in the pharmaceutical marketplace is a complex process involving a variety of stakeholders and myriad rebates, discounts, and fees
More informationBlueRx PDP. Link to Specific Guidance Regarding Exceptions and Appeals
BlueRx PDP Conditions and Limitations Potential for Contract Termination Disenrollment Rights and Instructions Exceptions, Prior Authorization, Appeals and Grievances Out-of-Network Coverage Quality Assurance
More informationH. R IN THE HOUSE OF REPRESENTATIVES
I 1TH CONGRESS 1ST SESSION H. R. 1 To ensure patient choice in pharmacies by regulating pharmacy benefit managers and to establish a program to improve access to prescription drugs for certain individuals.
More informationToday PBMs control the pharmacy benefits of more than 253 MILLION Americans.
The PBM Story Decades ago, insurance companies expanded their coverage to include prescription drugs. They turned to a new kind of company, a sort of middleman, to process prescription drug claims. For
More informationToday PBMs control the pharmacy benefits of more than 253 MILLION. 3 PBMs. Americans.
The PBM Story Decades ago, insurance companies expanded their coverage to include prescription drugs. They turned to a new kind of company, a sort of middleman, to process prescription drug claims. For
More informationValues Accountability Integrity Service Excellence Innovation Collaboration
n04231 Medicare Part D Transition and Emergency Fill Policy Values Accountability Integrity Service Excellence Innovation Collaboration Abstract Purpose: The Medicare Part D Transition and Emergency Fill
More informationPart II: Medicare Part C and Part D
Part II: Medicare Part C and Part D Part II: Part C and Part D Part C (Medicare Advantage)... 1 Enhanced Payments to Plans for Certain Beneficiary Types... 1 Special Needs Plans: Enrollment of Medicare
More informationMedicare Modernization Act (MMA)
Medicare Modernization Act (MMA) Julian Whitekus SEAC Conference Charlotte, N.C. November 16 18, 2005 WHAT IS AT STAKE : Projected U.S. Retail Rx Drug Spending 2005 (Total = $223.5 billion) 2006 (Total
More informationMEDICARE PART D POLICY FORMULARY: TRANSITION PROCESS Policy Number: 6-C
MEDICARE PART D POLICY FORMULARY: TRANSITION PROCESS Policy Number: 6-C Coverage Statement This Policy is applicable to: Medco PDP, Beneficiaries, Enhanced PDPs, Client PDPs and Client MA-PDs, to the extent
More informationIMPACT OF THE ELIMINATION OF PREFERRED PHARMACY NETWORKS ON THE MEDICARE PART D PROGRAM
IMPACT OF THE ELIMINATION OF PREFERRED PHARMACY NETWORKS ON THE MEDICARE PART D PROGRAM March 7, 2014 CHRIS CARLSON FSA, MAAA RANDALL FITZPATRICK FSA, MAAA Prepared for: Considerations and Limitations
More information2011 Summary of Benefits
2011 Summary of Benefits (PDP) and January 1, 2011 December 31, 2011 BlueCross BlueShield of South Carolina contracts with the federal government. Contract # s5953 (PDP) s5953_pdp2011sb cms approved 08312010
More informationTHE GENERAL ASSEMBLY OF PENNSYLVANIA SENATE BILL INTRODUCED BY EICHELBERGER, ARGALL, RAFFERTY, VULAKOVICH AND BROWNE, MAY 18, 2018 AN ACT
PRINTER'S NO. THE GENERAL ASSEMBLY OF PENNSYLVANIA SENATE BILL No. Session of 01 INTRODUCED BY EICHELBERGER, ARGALL, RAFFERTY, VULAKOVICH AND BROWNE, MAY 1, 01 REFERRED TO BANKING AND INSURANCE, MAY 1,
More informationCody Wiberg, Pharm.D., M.S., R.Ph. Executive Director Minnesota Board of Pharmacy
Cody Wiberg, Pharm.D., M.S., R.Ph. Executive Director Minnesota Board of Pharmacy UNITED STATES MILITARY CANADIAN MILITARY Pharmacy Preferred Providers as Selected by Drug Manufacturers and Third
More informationPay for Performance & the Changing Landscape for Pharmacy: A Panel Discussion
Pay for Performance & the Changing Landscape for Pharmacy: A Panel Discussion Panelists: Mark Conklin, Pharmacy Quality Solutions Alex Cruz, Healthfirst Crystal Lennartz, Health Mart Jesse McCullough,
More informationGlossary of Terms (Terms are listed in Alphabetical Order)
Glossary of Terms (Terms are listed in Alphabetical Order) Access Access refers to the availability and location of pharmacies that participate in the network that serves your pharmacy benefit plan. Acute
More informationSummary of Benefits. January 1 December 31, 2011
Summary of Benefits January 1 December 31, 2011 Section 1: Introduction to the Summary of Benefits Report for Medco Medicare Prescription Plan (PDP) January 1, 2011 December 31, 2011 Thank you for your
More informationSummary of Benefits. My RxBLUE (PDP). Medicare prescription drug plan from the Cross and Shield 10MX0010 R1/11 S5937_091010AMFU
2011 Summary of Benefits 2011 My RxBLUE (PDP). Medicare prescription drug plan from the Cross and Shield 10MX0010 R1/11 S5937_091010AMFU Summary of Benefits for RxBLUE (PDP) January 1, 2011 December 31,
More informationSecurityBlue HMO. Link to Specific Guidance Regarding Exceptions and Appeals
SecurityBlue HMO Conditions and Limitations Potential for Contract Termination Disenrollment Rights and Instructions Exceptions, Prior Authorization, Appeals and Grievances Out-of-Network Coverage Quality
More information2019 Transition Policy
2019 Number: 5.8 Prescription Drug Replaces: 5.8 v.2018 Cross 5.1.2 Transition Fill Monitoring Procedure References: Purpose: To provide guidance on the transition process for new or current Plan members
More informationTHIRD-PARTY PHARMACY RECONCILIATION
THIRD-PARTY PHARMACY RECONCILIATION Billy Caster Sales Solution Expert Inmar Healthcare Network Jon Brumbaugh Sr. Manager, Product Inmar Healthcare Network Session Description A discussion and presentation
More informationSummary of Benefits. Aetna Medicare Rx Costco Plus Plan (PDP) S5810. California. January 1, 2010 to December 31, 2010
January 1, 2010 to December 31, 2010 Summary of Benefits Aetna Medicare Rx S5810 California S5810_D_PE_SB_90712 (08/2009) Visit us www.aetnamedicare.com 1 Summary of Benefits: Aetna Medicare Rx Section
More informationPLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
Benefits and Premiums are effective January 01, 2018 through December 31, 2018 PHARMACY - PRESCRIPTION DRUG BENEFITS PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Prescription drug
More informationBlue Shield Medicare Basic Plan (PDP) Blue Shield Medicare Enhanced Plan (PDP)
Summary of Benefits January 1, 2014 December 31, 2014 State of California S2468_13_228 CMS Accepted 09102013 SECTION I INTRODUCTION TO SUMMARY OF BENEFITS Thank you for your interest in and. Our plans
More information2008 Medicare Part D: Pharmacist's Survival Guide. Ronnie DePue, R.Ph., CGP
2008 Medicare Part D: Pharmacist's Survival Guide Ronnie DePue, R.Ph., CGP Objectives At the completion of this program, the participant will be able to: 1. Give an overview of the Medicare Prescription
More informationThe Declining Value of Payer Access: Defining and improving Rebate Efficiency in the current healthcare landscape
The Declining Value of Payer Access: Defining and improving Rebate Efficiency in the current healthcare landscape Lucas Greenwalt, Senior Principal Amundsen Consulting Prepared for: CBI Gross to Net Boot
More information2012 Medi-Pak Rx (PDP) Prescription Drug Plans. S5795_REV_RX_FF_KIT_10_11 CMS Approved This is an advertisement.
2012 Medi-Pak Rx (PDP) Prescription Drug Plans S5795_REV_RX_FF_KIT_10_11 CMS Approved 07222011 This is an advertisement. Rx AG BK Choose a Medi-Pak Rx (PDP) prescription drug Blue Shield for savings, convenience
More informationJanuary 25, 2019 RE: CMS-4180-P. Dear Administrator Verma:
NATIONAL ASSOCIATION OF SPECIALTY PHARMACY 300 New Jersey Ave., Suite 900 Washington, DC 20001 www.naspnet.org January 25, 2019 Ms. Seema Verma, MPH Administrator Centers for Medicare & Medicaid Services
More informationBlue Cross MedicareRx (PDP) SM
(PDP) SM Summary of Benefits January 1, 2014 December 31, 2014 Y0096_BEN_IL_PDPSB14 Accepted 10012013 31980.0613 SECTION I Introduction to the Summary of Benefits for SM January 1, 2014 December 31, 2014
More informationMedicare Prescription Drug, Improvement and Modernization Act
International Journal of Health Research and Innovation, vol. 1, no. 2, 2013, 13-18 ISSN: 2051-5057 (print version), 2051-5065 (online) Scienpress Ltd, 2013 Medicare Prescription Drug, Improvement and
More informationHow the Blueprint Policy Statement to Lower Drug Costs and Reduce Out-of- Pocket Costs May Affect Employers
How the Blueprint Policy Statement to Lower Drug Costs and Reduce Out-of- Pocket Costs May Affect Employers Presented by: Lorie Maring Phone: (404) 240-4225 Email: lmaring@ AGENDA Provide an overview of
More informationMedicare Transition POLICY AND PROCEDURES
Medicare Transition POLICY AND PROCEDURES POLICY The Plan will maintain an appropriate transition process, consistent with 42 CFR 423.120(b)(3), Chapter 6 of the Medicare Prescription Drug Benefit Manual
More information2010 Summary of Benefits S5601
P.O. Box 280200, Nashville, TN 37228 Contact SilverScript Insurance Company for more information about our plans NOTE: Please contact us if you have questions or concerns about our plans. representatives
More informationThe Medicare Drug Benefit: Options for Low-Income Californians in None None $1.05 generic / $3.10 brand; none after $5,726.
The Medicare Drug Benefit: Options for Low-Income Californians in 2008 C A LIFORNIA HEALTHCARE FOUNDATION Overview At the end of 2007, approximately 500,000 low-income Californians participating in the
More informationMEDICARE PRESCRIPTION DRUG PART D COMPLIANCE CONFERENCE. Reporting Requirements: Audit Preparedness for PDPs and Manufacturers
MEDICARE PRESCRIPTION DRUG PART D COMPLIANCE CONFERENCE Reporting Requirements: Audit Preparedness for PDPs and Manufacturers Polaris Management Partners 8:30 9:30am Concurrent Breakout Session AGENDA
More informationAppendix. Year Total drug spending reaching catastrophic coverage, $
Appendix Exhibit A. Low-income Subsidy Copayments in 2006-2012 Year 2006 2007 2008 2009 2010 2011 2012 Total drug spending reaching catastrophic coverage, $ 5100 5451.25 5726.25 6153.75 6440 6447.5 6657.5
More informationMedicare Advantage Part D Pharmacy Policy
Page 1 of 27 DISCLAIMER NOTICE: The purpose of this policy is to provide guidance for benefit and coverage determinations only. Benefit and coverage determinations are subject to the contractual limitations
More information2018 Medicare Part D Transition Policy
Regulation/ Requirements Purpose Scope Policy 2018 Medicare Part D Transition Policy 42 CFR 423.120(b)(3) 42 CFR 423.154(a)(1)(i) 42 CFR 423.578(b) Medicare Prescription Drug Benefit Manual, Chapter 6,
More information(PDP) Prescription drug coverage for Medicare beneficiaries Blue Medicare Rx (PDP) Y0079_XXX CMS Approved MMDDYYYY
2014 Blue Medicare Rx (PDP) Prescription drug coverage for Medicare beneficiaries (PDP) Y0079_XXX CMS Approved MMDDYYYY Y0079_6354 CMS Accepted 08272013 U5073a, 8/13 Contents Your guide to Blue Medicare
More informationVia Electronic Submission at: www. regulations.gov. January 25, 2019
Via Electronic Submission at: www. regulations.gov The Honorable Seema Verma Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services (HHS) Attn: CMS-4180-P P.O.
More informationPharmacy Benefit Managers Overview
Pharmacy Benefit Managers Overview A Presentation to the House Health Innovation Subcommittee Mary Alice Nye, Ph.D. Health and Human Services Staff Director, OPPAGA December 6, 2017 Pharmacy Benefit Managers
More informationThe U.S. Healthcare System: How Pharmacy Benefit Managers Impact Prescription Drug Use. Presented by Daniel Tomaszewski Pharmd, PhD
The U.S. Healthcare System: How Pharmacy Benefit Managers Impact Prescription Drug Use Presented by Daniel Tomaszewski Pharmd, PhD 1 Medical Vs. Pharmacy Coverage Medical Insurance Managed by an Insurance
More informationAetna Medicare 2015 Benefits at a Glance
Aetna Medicare 2015 Benefits at a Glance Aetna Medicare Rx Saver (PDP) Aetna Medicare Rx Premier (PDP) Arizona, California, Florida, Nevada, South Carolina 58.02.396.1-NPREF Contact us for answers to your
More informationEstimate of Medicare Part D Costs After Accounting for Manufacturer Rebates
October 2016 Estimate of Medicare Part D Costs After Accounting for Manufacturer Rebates A Study of Original Branded Products in the U.S. $ Introduction The cost of medicines in the U.S. has been the subject
More informationProvisions of the Medicare Modernization Act
Provisions of the Medicare Modernization Act Medicare Prescription Drug Modernization and Improvement Act of 2003 (MMA) Todd Whitney, FSA, MAAA Wakely Consulting Group Highlights of New Act New Rx Benefit
More informationIntroduction to the Use of Medicare Part D Data for Research. Minneapolis MAY 15-16, 2013
Introduction to the Use of Medicare Part D Data for Research Minneapolis MAY 15-16, 2013 Educational Objectives of Workshop Understand the Medicare Part D Program and its benefits Understand what demographic,
More information2019 Summary of Benefits
2019 Summary of Benefits Jan. 1, 2019 Dec. 31, 2019 888-645-6025 TTY 711 Seven Days a Week, 8 A.M. to 8 P.M.(Oct. 1, 2018, to Mar. 31, 2019) Monday-Friday, 8 A.M. to 8 P.M. (All Other Times) (PDP) (PDP)
More informationStrategies to Increase CMR Completion Rates in Medicare MTM Programs
Strategies to Increase CMR Completion Rates in Medicare MTM Programs Erwin Jeong, Pharm.D., FCSHP Clinical Operations Manager, Medicare MTM Program Kaiser Permanente, Southern California October 29, 2016
More informationUnique PBM Capabilities
Gaining Lives With Our Unique PBM Capabilities Jon Roberts Executive Vice President & President, CVS/caremark Agenda Performance Highlights Pharmacy Trends and Cost Management Programs Well Positioned
More informationJanuary 25, Re: Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Outof-Pocket Expenses [CMS 4180 P] RIN 0938 AT92
January 25, 2019 [Submitted electronically via www.regulations.gov] The Honorable Seema Verma Administrator Centers for Medicare & Medicaid Services U.S. Department of Health and Human Services Attention:
More informationThe 2018 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers
The 2018 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers Adam J. Fein, Ph.D. Drug Channels Institute February 2018 Full report available at http://drugch.nl/pharmacy COPYRIGHT Copyright
More informationSummary of Benefits 2011
Summary of Benefits 2011 This Summary of Benefits tells you some features of our plans. AARP Rx AARP Rx January 1, 2011-December 31, 2011 S5820 S5921 SBPDP3251059_XABE000 Y0066_PDP3238383_000 CMS Approved
More informationMedicare Beneficiary Costs Set to Rise for Part D Drug Benefit in 2010
Fact Sheet AARP Public Policy Institute Medicare Beneficiary Costs Set to Rise for Part D Drug Benefit in 2010 Medicare beneficiaries who will participate in Part D for 2010 should examine their plan choices
More informationMedicare Modernization Act and Medicare Part D: Status of Implementation
Medicare Modernization Act and Medicare Part D: Status of Implementation November 1, 2005 John Richardson Avalere Health LLC Avalere Health LLC The intersection of business strategy and public policy What
More informationUnderstanding Pharmacy Benefit Management Services
Understanding Pharmacy Benefit Management Services Peter Cullen VP, Business Development and Strategic Initiatives March 12, 2014 Innovation Session Overview and Learning Objectives Session Overview: Provide
More informationAmerigroup Medicare Member PBM Conversion Talking Points
Amerigroup Medicare Member PBM Conversion Talking Points Overview On January 1, 2015, pharmacy benefits for L-Amerigroup Amerivantage (AMV) members will be covered through Express Scripts, Inc. (ESI).
More informationSummary of Benefits. Regence Medicare Script TM. Enhanced (PDP) Basic (PDP) Medicare Prescription Drug Plan for Utah
2013 Summary of Benefits Medicare Prescription Drug Plan for Utah Regence Medicare Script TM Enhanced (PDP) Regence Medicare Script TM Basic (PDP) Regence BlueCross BlueShield of Utah is an Independent
More informationNCPA Summary of CMS Medicaid Covered Outpatient Drugs AMP Final Rule Prepared January NCPA Advocacy at Work
NCPA Summary of CMS Medicaid Covered Outpatient Drugs AMP Final Rule Prepared January 2016 The Centers for Medicare & Medicaid Services (CMS) recently issued a 658-page, oftendelayed, final rule on the
More informationSan Francisco Health Service System Health Service Board
San Francisco Health Service System Health Service Board HSS Rates & Benefits Committee Meeting City Plan (UHC) Employer Group Waiver Plan (EGWP) + Wrap Presentation April 12, 2012 Prepared by Aon Hewitt
More informationPREMIUM IMPACT OF REMOVING MANUFACTURER REBATES FROM THE MEDICARE PART D PROGRAM
PREMIUM IMPACT OF REMOVING MANUFACTURER REBATES FROM THE MEDICARE PART D PROGRAM July 6, 2018 RANDALL FITZPATRICK FSA, MAAA CHRIS CARLSON FSA, MAAA CONTENTS Executive Summary... 2 Data and Methodology...
More informationOhio. Benefits effective January 1, 2010 (S ) PDP Option 1 (PDP) (S ) PDP Value Option 2 (PDP)
2010 Health Net ORANGE option 1/value option 2 (PDP) prescription drug plan SUMMARY OF BENEFITS Ohio Benefits effective January 1, 2010 (S5678-034) PDP Option 1 (PDP) (S5678-033) PDP Value Option 2 (PDP)
More informationRestructuring the Medicare Part D Benefit with Capped Beneficiary Spending
Restructuring the Medicare Part D Benefit with Capped Beneficiary Spending Estimating the impact of capping Medicare Part D beneficiary spending, reducing federal reinsurance, and moving the coverage gap
More informationPURPOSE OF THE POLICY STATEMENT OF THE POLICY PROCEDURES
PURPOSE OF THE POLICY The purpose of this policy is to describe Health Alliance s process for transitions and ensure that continued drug coverage is provided to new and current Part D members. The transition
More information