Group Health

2020 Readiness Checklist for Medicare Advantage Organizations & Prescription Drug Plans

Last month, HPMS released a memo outlining its 2020 Readiness Checklist for Medicare Advantage Organizations and prescription drug plans.

The Centers for Medicare and Medicaid Services recommends all Medicare Advantage and prescription drug plans review the checklist – and take the appropriate action to meet the requirements next year. Health plans should closely review the entire checklist to ensure compliance. Remember, the checklist isn’t a compilation of suggestions from the government. Instead, it’s a summary of the most critical requirements.

Here’s a few examples of what’s in the readiness checklist for 2020:

Medicare Plan Finder Data. Part D Sponsors must provide access to the Health Plan Management System Part D Pricing File Submission Module.

Prescription Drug Event Requirements. Part D Sponsors must submit the data CMS needs to carry out payment provisions through the Prescription Drug Front-End System and processed by the Drug Data Processing System.

Coverage Gap Discount Program. The agency is asking Part D Sponsors to understand their responsibilities to participate in the CGDP, and provides information about the CGDP portal, onboarding training and more.

Precluded Providers and Prescribers. CMS has bigger expectations for 2020 when it comes to managing precluded providers and prescribers. Moving forward, MAOs/Part D Sponsors must, when when a prescriber is on the Preclusion List, deny payments for reject a pharmacy claim, deny a beneficiary request for reimbursement, or deny a health care service.  

What Can Your Health Plan Do Next Year? 

Tier 1 Pharmacy Consuting can make a readiness assessment for your health plan or prescription drug plan to ensure you are prepared and identify potential problems before they begin.

Get Started 

Tier 1 Pharmacy Consulting can work with your staff so everyone understands his or her responsibilities and how to successfully tackle them. We can help you develop a Star Ratings plan for 2021 that will help your health plan improve its performance and achieve your goals.

Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program. With us, you can rest assured that making changes doesn’t have to be complicated or overwhelming. It’s important that you earn the highest rating possible.

A four or five star rating is within your reach for 2021. We can help you get there.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.

CMS Star Ratings Sees Improvements This Year

CMS Releases Star Ratings

Last month, the Centers for Medicare and Medicaid Services its released its Star Ratings findings for 2020 with some great news: More plans rated four stars or higher this year compared to the year before. 

To get more specific, more than 50 percent of plans rated four and above, up from 45 percent. In addition, the enrollment weighted average increased from 4.06 last year to 4.16 this year. Twenty plans earned five stars, yet another sign of continued improvements. 

Why Does it Matter? 

Most Medicare Part D and Medicare Advantage plans understand the importance of Star Ratings. The ratings are put out annually by the Centers for Medicare and Medicaid Services to give beneficiaries a look at the quality of the health plan before they sign up. Star Ratings focus on aspects of high-quality care within the control of the plan. They provide a complete, accurate, reliable, and valid picture of a program. Star Ratings also are used for compliance and monitoring, and measure aspects of a plan that are relevant and important to beneficiaries. CMS looks to NCQA, PQA and others for measure concept development, endorsement, and specifications.

Star Ratings are displayed on the Medicare Plan Finder – which recently got a huge facelift – so seniors may consider both quality and cost in their enrollment decisions. In other words, Star Ratings are very important.

Other Key Findings 

CMS also found that: 

– More than 80 percent of beneficiaries are now enrolled in plans with 4 or more stars, up from 75 percent last year. 

– This year, 141 plans earned higher 2020 ratings than they did in 2019. 

– Only 57 health plans saw their overall ratings drop year-over-year.

– This year, 56 plans earned a4th star. 

– Only 21 plans lost their 4th star this year.

– Approximately 52 percent of contracts for Medicare Advantage plans offering Part D coverage earned 4 stars or higher, compared to about 45% in 2019.

– Of 401 total plans for 2020, 210 are at 4 stars or higher, compared to 172 in 2019 when there were fewer plans – 376 to be exact. 

– The comparison between 2020 and 2019 shows 55 contracts rated 3 stars for 2020 as opposed to 66 in 2019.

– The average star rating for a stand-alone prescription drug plan has improved from 3.34 in 2019 to 3.50 in 2020.

– There’s about 1,200 more Medicare Advantage plans operating in 2020 than in 2018, according to the Centers for Medicare and Medicaid Services. 

What Can Your Health Plan Do Next Year? 

If you didn’t achieve four stars this year, you have time to improve and influence your 2021 ratings with the right strategy, data, and attention to detail. It’s important that you review your current performance figures and use the right resources moving forward. 

If you earned four stars this year – congratulations! However, now is not the time to sit back and relax. Star Ratings is a competitive process, and the health plans who get top billing have already started taking steps to ensure the same if not better performance next year. 

Get Started 

Tier 1 Pharmacy Consulting can work with your staff so everyone understands his or her responsibilities and how to successfully tackle them. We can help you develop a Star Ratings plan for 2021 that will help your health plan improve its performance and achieve your goals.

Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program. With us, you can rest assured that making changes doesn’t have to be complicated or overwhelming. It’s important that you earn the highest rating possible.

A four or five star rating is within your reach for 2021. We can help you get there.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.

CMS Seeks Comments on Proposed Audit Protocol Changes for 2020

The Centers for Medicare and Medicaid Services (CMS) announced in a recent memo that officials are seeking comments to their proposed audit program protocol changes. This blog will outline some of the most important changes and a reminder of steps health plans can take if they receive a CMS audit notification.

Key Proposed Changes Through 2020

  • Formulary Administration “‘Website” section removal of the Audit Process and Data Request
  • Transition sample size from 15 to 30
  • Removal of the CPE Self-Assessment Questionnaire and the ODAG Supplemental Questionnaire
  • Removal of ‘Dismissals’ from the data integrity sampling
  • Removal of OD approved cases from the Clinical Decision Making section
  • Increased the Grievance sample size 
  • Removal of ‘Enrollment Verification’ audit element for SNP MOC
  • Removal of the Medication Therapy Management audit area 

For the full list and a closer look at all of the proposed changes to audit protocols, check out the memo here.  CMS is accepting comments through Oct. 15.

Many of the changes would reduce the burden on health plans. Even so, health plans should review any and all changes. The chance of a plan getting a program audit has increased and continues to grow. CMS is now reaching out to nearly 100% of plans every four via plan audits. Audit notice letters are typically sent March through July.

Plans should take steps sooner rather than later to address the changes and anticipate an audit in the future. The best way to deal with a CMS audit is to be prepared.

We can help. 

The team at Tier 1 Pharmacy Consulting provides support and consultation for all types of audits. We can review data to ensure accuracy with file layout requirements, interpret data to identify potential issues, craft responses, create corrective action plans and more. With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions and help you through the process from start to finish.

Tier 1 CEO Brent Hiley has been both the lead for CDAG (coverage determinations, appeals and grievances), the lead for FA (formulary administration) and even overall audit director, ensuring coordination of all elements related to data requests, deliverables, impact analysis and root cause summaries. He can provide onsite audit support for teams to ensure they are prepared for various questions that might be asked and coach them on how to approach certain aspects of the audit.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

CEO Brent Hiley is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

Drop us a note at info@tieronepc.com. We’re here to guide your health plan every step of the way.

Drug manufacturer rebate audit: Are you owed money?

There is one kind of audit a health plan actually wants: A drug manufacturer rebate audit. 

What is a drug manufacturer rebate audit? 

A drug manufacturer rebate audit is an in-depth look at a health plan’s rebate agreement previously put in place by drug manufacturers and a pharmacy benefit manager. The idea behind a rebate audit is to ensure that a health plan is recouping the most money possible through its drug benefit.  

Why should health plans seek rebates from drug companies? 

Brand-name prescription drugs are expensive, especially for medications that treat many serious, yet common medical conditions. Rebates are often the deciding factor when a health plan chooses to cover a drug and how much of the cost should be covered by a patient. 

Medicare Part D members, for example, are likely to pay anywhere between $12.40 and $77.40 and higher for prescription drug coverage, according to Medicare.gov, and that doesn’t include the required copay when you get to the pharmacy counter, which runs anywhere from $5 for generic drugs and $25 to $40 for name brand prescription medications. There are many reasons a health insurer may choose to cover or not cover a name brand prescription drug, but manufacturer rebates are a big one. 

How does a drug manufacturer rebate audit work? 

A drug manufacturer rebate audit analyzes the rebate agreements that exist between a health plan and drug manufacturers – typically the top five to ten manufacturers that contract with the PBM. The top is selected based on dollar value of the rebates on the drugs, often the top 50% to 75% of all rebates invoiced. 

Very few health plans conduct drug rebate audits. But as the possibility of more money to recoup grows, audits are likely to increase as well. Plans often are not receiving the level of rebates they are entitled to due to formulary exclusivity provisions in the contract. Or, competitor drugs on the formulary have limited PBM rebates. At the same time, incorrect goals and invoicing can result in wrong or limited rebate payments to the health plan. 

A drug manufacturer rebate audit can identify all of those problems and more. Many audits are conducted annually; sooner if there have been recent changes to PBM payments or the plan. Most Medicare Advantage plans report directly and indirectly to the Centers for Medicare and Medicaid Services (CMS). CMS expects rebate oversight if it conducts its own audit.

How do health insurers choose an drug manufacturer rebate auditor? 

An independent auditor must have lengthy experience in drug manufacturer rebate audits. The process is complicated at best. It’s also wise to have a consultant there to guide you through the process, which can take months. A team of experts assisting can help ensure you get the rebates the health plan is entitled to receive.

Tier 1 Pharmacy Consulting can help 

The team at Tier 1 Pharmacy Consulting works closely with health plans on every single aspect of their prescription drug benefits. Health plans are always looking to do more — but sometimes the resources just are not there. Let Tier 1 assist you with opportunities that might be limited by time and resources – including the chance of recouping drug manufacturer rebates. 

We want the same thing as our clients and their members: high quality prescription drug options at the lowest possible cost. We are sensitive to the need for lower prescription drug costs. At the same time, we believe it’s important to increase the value that the plan provides, and look for savings and rebates whenever possible. 

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

Drop us a note at info@tieronepc.com. Let’s get connected.

Should my health plan outsource or handle CMS compliance in-house?

Why You Should Outsource Your Health Plan Headaches

Benjamin Franklin once said nothing in this world is certain except death and taxes. In twenty-first century America, this quote could be updated with a refrain: Nothing is certain except death, taxes, and the labyrinthine nature of our healthcare system.

Right now, the United States is in a state of flux when it comes to health care compliance. As lawmakers move towards different ends of the spectrum when it comes to how health care should be managed in this country, and by whom, health plans are often left to muddle through endlessly complex and quickly-changing rules and regulations. Changes occur so quickly in the health care space that it can seem like the Centers for Medicare and Medicaid Services are throwing out new regulations by the day. How can health plans keep up with the pace while also focusing on their clients’ needs and meeting their bottom line?

The answer is simple: by partnering with Tier 1 Pharmacy Consulting, health plans free up hours in their workday and save their employees time and countless headaches. CMS audits, guidelines, regulations, and changes to all of the above can be confusing. Outsource the work to us and your health plans will never have to worry about important business decisions falling through the cracks – possibly costing thousands of dollars and years of scrutiny.

Pharmacy Benefits Don’t Have To Be Complicated

At Tier 1, our goal is simple: Offer our health plan customers strategic, cost-saving solutions that boost the plan’s overall value and help its members by proving high-quality care. The way we go above and beyond that goal is just as simple: We offer a full suite of services designed specifically to save health plans both time and money.

Is your health plan well-versed on CMS’s 2019 update to the agency’s audit program? Every year, the CMS conducts thousands of audits, from BID audits to Formulary Administration audits, Transition Monitoring Program analysis, Data Validation audits and more. For some health plans, it would take a year just to work through the 2019 update, let alone take measures to prepare for the audits that may come along at any time. Tier 1 helps hundreds of plans a year by taking the grunt-work out of audit preparation: by outsourcing audit woes to Tier 1, health plans not only save time and money, but also greatly reduce their chances of paying fines due to accidental oversight.

Audits are just one example of what Tier 1 can offer health plans to make their schedules lighter and more able to innovate in other ways. We also help health plans to get answers to compliance questions more efficiently by acting as a liaison between them and pharmacy benefit managers. If your health plan has ever had questions about something as deceptively simple as website management or as straightforwardly complex as finding a new pharmacy benefit manager altogether, let Tier 1 help: we have the expertise and the insight needed to help health plans and PBMs get on the same page fast.

Reach Out Now and See What’s Possible

What would your health plan do if they didn’t have to worry about the endless complexities of CMS rules and PBM issues? It’s time to start thinking big. Hire Tier 1 Pharmacy Consulting today and start to see what’s possible for the future of your health plan.

Get in touch.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.


What can Tier 1 Do for Your Health Plan?

Take a second look at what we do.

Tier 1 Pharmacy Consulting prides itself on adding value to their clients’ businesses not only through the services it offers, but also by engaging in frequent knowledge-sharing via its online blog. Regulations, standards, and methods of operation in the overlapping worlds of health care, health plans, and pharmaceuticals can shift in the blink of an eye. If health plans don’t stay abreast of the latest laws, the penalties can be severe. Tier 1 takes their responsibility of educating and guiding its clients through complex guidelines seriously—and if you’re new to us, clicking through our blog archives will demonstrate how the depth and breadth of Tier 1’s knowledge base can have a meaningful impact on your health plan—and your bottom line.

This week, we’re shining the spotlight directly on Tier 1 and the many ways this company can help health plans do their best work for their own clients while remaining in compliance. Read on to find out why our thought leadership is just one reason to partner with us.

Founded with the Client in Mind: Tier 1’s Story

Tier 1 was founded in order to meet one core goal: Help health plans across the country to develop effective strategies and improve health plan outcomes. Each and every staff member from Tier 1 assigned to a client is an expert at making great plans even better, and improving plans that haven’t yet met their own goals due to lack of time or resources.

“I created Tier 1 because I know firsthand how complex the pharmacy and health care industries can be,” comments founder and CEO Brent Hiley. “I’ve spent my entire professional life as a pharmacist, and subsequently a pharmacist benefit manager—these experiences gave me the insights and expertise needed to help health plan administrators navigate through a complicated and heavily regulated world.”

Tier 1’s mission and methods are directly inspired by Mr. Hiley’s first-person experience. The company recognizes the importance of health plans in the larger world of health care—when operating effectively and efficiently, they can help cut costs through patient adherence, drug utilization, and regulatory compliance. The most effective health plans are able to seamlessly integrate specific requirements—and Tier 1 helps their clients accomplish this through multiple avenues of service, ranging from the simple to the complex.

Collaboration, Insight, Expertise: How Tier 1 Can Help Your Health Plan at Every Stage

Tier 1 offers a full suite of services to its health plan clients. These services include interim management support, application support, audit support, clinical strategy, compliance, delegation oversight, operations, risk assessment, policy writing and material review, and RFP initiatives. Much of what Tier 1 does is geared towards taking the substantial workload off client’s shoulders so they can focus more on the needs of their patients. Other services focus specifically on a simple and universal goal: saving clients money. By hiring an external consultant to conduct audits, as just one example, health plan administrators can save themselves thousands of dollars—and a similar number of headaches—down the line.

“Simply put, Tier 1 employees are experts in streamlining your health plans so that you can make the most of your bottom line without sacrificing customer care,” comments Mr. Hiley. “We are driven by our client’s satisfaction—and have happily helped thousands of health plans meet their needs effectively.”

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

Drop us a note at info@tieronepc.com. Let’s get connected.

CMS FAQ’s to Audit Program: What You Should Know

The Centers for Medicare and Medicaid Services receives hundreds, if not thousands, of emails from health plans with questions about changes and updates to the agency’s audit program. In many cases, CMS says, the same answers are sought. Because of that, the agency has published an outline of the questions organizations tend to ask most frequently.

A little background: CMS releases changes and updates to its Program Audit Process every year so health plans know what to expect in the event they are audited. Such probes include CMS program audits, PDE audits, one-third Financial audits, BID audits, Formulary Administration audits, Transition Monitoring Program Analysis, Coverage determination/redetermination Timeliness audits and Data Validation audits.

Medicare plans and pharmacy teams are increasingly subject to closer CMS monitoring and review, so an audit is more likely now than ever before. Typically, CMS audits plans once per audit cycle, which runs between three to five years. Even so, it’s important to be ready for an audit – especially if your health plan has performance issues.

Audit notifications for 2019 will be sent out starting this month. If you receive a notification, give us a call. The team at Tier 1 Pharmacy Consulting provides support and consultation for all types of audits. We can review data to ensure accuracy with file layout requirements, interpret data to identify potential issues, craft responses and create corrective action plans. With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions to ensure compliancy and get you through the process.

Back to the FAQ. Below,  we highlight a few things health plans are most concerned about. The entire CMS article can be found here: https://go.cms.gov/2J7kR4b

Universe Submissions

CMS has tips for preparing universe submissions in the hopes of making the process a little smoother on both sides. For example, the agency suggests that plans direct any universe questions that arise to the area Team Lead before submission. Plans also should answer “not applicpable” answers as “NA” not “N/A” as seen on many question and answer forms.

Compliance Program Effectiveness (CPE)

CMS has started collecting Call Logs, which help identify misclassification of coverage requests during the Compliance Program Effectiveness portion of an audit. The agency plans to use other ways to look at requests that are filed incorrectly, such as reviewing how well a plan oversees the call-routing process.

Health plans should expect to be evaluated. However,  collection of call log data is suspended for 2019.  Health plans should still add call log auditing and monitoring activities to their to-do lists and have a documented oversight process in place.

Part D Formulary and Benefit Administration (FA)

CMS says the Medicare Beneficiary Identifier (MBI) or Health Insurance Claim Number (HICN) can be populated for FA record layouts currently requiring submission of an HICN. CMS also indicated that New Member Layout should be populated to include only enrollees for which the plan does not utilize prior claims history.

Have questions for CMS? Email the Parts C and D mailbox at part_c_part_d_audit@cms.hhs.gov or the Medicare-Medicaid Coordination Office at mmcocapsmodel@cms.hhs.gov.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

Drop us a note at info@tieronepc.com. Let’s get connected.

CMS Reverses Formulary Design Rule Starting in 2020. Get Ready Now

The Centers for Medicare and Medicaid Services has reversed its rule prohibiting formulary design that would expand prescription drug choices for Part D health plans and their members.

CMS in August announced that starting in 2020 it will allow Medicare Part D plan sponsors to implement indication-based formulary design. That means plans can cover specific indications of a drug and negotiate lower drug prices, according to a CMS statement.

This is good news.

What is indication-based formulary design? It’s a formulary management tool that allows health plans to tailor on-formulary coverage of drugs predicated on specific indications. Under this type of formulary design, health plans have the ability to negotiate formulary coverage based on specific indications.

Currently, CMS requires Part D plans to cover a drug for every indication approved by the U.S. Food and Drug Administration. The only exceptions are drugs used for treatments statutorily excluded from Part D coverage.

The current authorization criteria is complex at best, and preferred formulary indications must be included in coverage. Medicare Part D plan sponsors are able to use utilization management tools, such as step therapy and prior authorization requirements to promote cost-effective drug therapy by encouraging the use of preferred formulary agents.

According to CMS, the change essentially will give Medicare Part D the power to tailor which drugs are on their formulary by specific indications. They will in turn have additional negotiating leverage with manufacturers, CMS says, which can reduce beneficiary and program costs. As CMS says: “If a Medicare Part D plan sponsor chooses to tailor on-formulary coverage of drugs to certain indications, it must ensure that there is another therapeutically similar drug on the formulary for the non-covered indication in order to meet the anti-discrimination requirements described in section 1860D-11(e)(2)(D)(i) of the Social Security Act.”

The change will likely promote diversity of formularies, which means patients will have greater access to lower drug costs, which promotes better health in the long run. Patients also won’t have to rely on an appeal to get the type of drug treatment they need, CMS says.

Plans should now begin to plan the steps they will be required to take to ensure compliance. Part D sponsors will have to update their applicable CY 2020 beneficiary materials to ensure that the presence of indication limitations is displayed to prospective enrollees. If a Medicare Part D plan sponsor opts to implement indication-based formulary design for CY 2020, the plan must disclose that some drugs may be subject to these requirements in the plan’s Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents.

It’s going to be a lot of work – complicated work that many plans don’t have the time or expertise to accomplish properly. That’s where Tier 1 Pharmacy Consulting can help.

The Tier 1 team will ensure CMS compliance by developing and reviewing all of the formularies and updating marketing materials. Contact us today.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.

Think it’s Too Early for 2020 CMS Star Ratings? Think Again

The Centers for Medicare and Medicaid Services released its 2019 Star Ratings last month – which already has some health plans thinking about 2020.

If it seems far off, it’s really not. That’s because it takes time to ensure your health plan is doing everything it can to ensure a four or five star rating. It’s a challenging task, but it’s feasible.

Star Ratings are put out by CMS to give Medicare and Medicaid beneficiaries some insight into the quality of the health plan before they sign up.

Among other things, Star Ratings:

– Measure aspects of a plan that are relevant and important to beneficiaries. CMS looks to NCQA, PQA and others for measure concept development, endorsement and specifications.

– Focus on aspects of high-quality care within the control of the plan.

– Provide a complete, accurate, reliable, and valid picture of a health plan. Star Ratings also are used for compliance and monitoring.

Star Ratings are displayed on the on Medicare Plan Finder (MPF) so beneficiaries may consider both quality and cost in enrollment decisions. The Affordable Care Act established CMS’s Star Ratings as the basis of Quality Bonus Payments to MA plans. Beneficiaries can join a five star plan at any time through a special enrollment period.

How can you work to receive a higher rating in 2020? Let the team at Tier 1 Pharmacy Consulting help. We are experts in Medicare compliance.

Tier 1 Pharmacy Consulting can work with your staff so everyone understands his or her responsibilities and how to successfully tackle them. We can help you develop a Star Ratings plan for 2020 that will help your health plan improve its performance and achieve goals.

Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program. With us, you can rest assured that making changes doesn’t have to be scary. It’s necessary to get you the best rating possible. We will make sure your vendors are on board, too, supporting your efforts and all of the needs of the Star Ratings plan.

A four or five star rating is within your reach for 2020. We can help you get there.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.