CMS’ approaches to these and other issues are contained in its proposed rule for Contract Year 2019, Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program (CMS-4182-P).
“NACDS was pleased to see progress on several important issues in CMS’ proposed rule – including pro-patient and pro-pharmacy approaches on which NACDS has advocated,” said NACDS president and chief executive officer Steven Anderson.
“NACDS will remain engaged on these topics and will issue further comments as CMS continues its work on this proposal, particularly where there are opportunities to shape policies to achieve even better results for Medicare beneficiaries and for the pharmacies that serve them.”
NACDS analyzed for members the proposed rule’s provisions associated with these and other issues:
• Pharmacy “lock-in” programs related to opioid abuse prevention – In implementing provisions of the Comprehensive Addiction and Recovery Act of 2016, CMS proposed a definition of the term “locked-in pharmacy” that has been supported by NACDS. This term refers to a plan sponsor’s “lock-in” ability to require beneficiaries who are at-risk for prescription drug abuse or misuse to obtain frequently-abused drugs from selected prescribers and/or network pharmacies. CMS’ proposed definition of “locked-in pharmacy” acknowledges that pharmacies with multiple locations that share real-time electronic data should be treated as one pharmacy – thus maintaining the spirit of the law while making appropriate allowances for patients’ convenience.
• National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard for electronic prescribing – CMS is proposing the adoption of the NCPDP SCRIPT Standard Version 2017071 as the official electronic prescribing standard for transmitting prescriptions and prescription-related information in Medicare Part D. This is consistent with NACDS’ advocacy, and that of Surescripts. The transition would meet clinical and business needs alike.
• MTM and the Medical Loss Ratio – As urged by NACDS, CMS’ proposed rule could create a further incentive for plans to utilize MTM programs. Under current requirements, Part D plan sponsors and Medicare Advantage plans are required to meet a medical loss ratio of 85 percent, meaning the plan must not spend more than 15 percent on administrative functions. The goal is to force plans to spend more on patient care and on items such as quality improving activities (QIA). There has been confusion as to whether the services provided in the Part D MTM program are considered an administrative function or a QIA. CMS is proposing to clarify that Part D MTM programs will fall under the QIA side of the formula.
• Pharmacy networks – CMS is clarifying that Part D plan sponsors may not exclude pharmacies with unique or innovative business or care delivery models from participating in their contracted pharmacy network based on not fitting into the correct pharmacy type classification. Part D plan sponsors must not exclude pharmacies from their retail pharmacy networks solely on the basis that they, for example, maintain a traditional retail business while also specializing in certain drugs or diseases or providing home delivery service by mail to surrounding areas.
• Direct and indirect remuneration (DIR) fees – CMS is soliciting comments on proposed policies related to DIR fees. NACDS intends to acknowledge CMS’ clear recognition of pharmacies’ concerns about these fees, and NACDS will continue to urge CMS’ guidance on increased transparency in terms and conditions related to DIR fees, including the consistency and timing of these fees.
“NACDS will remain vigilant on the numerous, complex and highly consequential policies that ultimately affect pharmacy operations and pharmacy patient care. We will continue to articulate a pro-pharmacy and pro-patient voice as CMS advances its consideration of these issues, and we appreciate the progress that CMS is proposing on diverse and critical topics,” Anderson added.