Medicare Part D Archives • Tier 1 Pharmacy Consulting

OIG: CMS Should Do More to Reduce Medicare Fraud

August 20, 2019

The U.S. Department of Health and Human Services’ Office of Inspector General has called on the Centers for Medicare and Medicaid Services to take steps that officials believe would reduce fraud among Medicare Advantage and Medicare Part D plans.

In its 2019 report, “Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs: Top Unimplemented Recommendations” the OIG outlined its top recommendations to reduce fraud, abuse, and waste amount HHS programs, including Medicare.

This blog focuses on the recommendations for Part D and Advantage (also known as Part C) for this year.

OIG Unimplemented Recommendations

– CMS should tighten its oversight for Part D payments for compounded topical drugs, which are often at risk for fraud, waste and abuse. The OIG report found that spending on compounded drugs increased by nearly 180% between 2010 and 2016. For its part, CMS has released a reminder memo of its policies for compounded topical drugs, but OIG officials believe more steps should be taken.

– CMS should gather stronger, more consistent data from plan sponsors that includes information on the potential for fraud and abuse. By doing so, CMS oversight will improve to better detect and prevent fraud and other problems, the OIG says. Plans are not required to report potential fraud by pharmacies and providers to CMS – but they can by their own admission. Not as many do as the OIG would like, so it wants CMS to do a better job at data collecting. For its part, CMS has said it will start requiring plan sponsors to report their own data as well.

– Medicare Advantage plans should be required by CMS to include ordering and referring provider identifiers in their encounter data. Encounter data is information submitted by health care providers, such as doctors and hospitals that documents both the clinical conditions they diagnose as well as the services and items delivered to beneficiaries to treat these conditions. Ordering and referring provider identifiers is not always required in encounter data and was often overlooked, the OIG says. Officials wants CMS to require Medicare Advantage plans to include ordering and referring provider identifiers from here on out.

Summary

With these recommendations, health plans should anticipate stricter regulations and guidance requiring reporting of potential fraud by network providers and updates to encounter reporting requirements.

We Can Help

Tier 1 Pharmacy Consultants helps health plans navigate the often murky and confusing waters of CMS changes, regulations, and oversight. The rules change often, and it’s difficult for health plans to keep up, much less stay compliant. Our team can help.

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.

Drug manufacturer rebate audit: Are you owed money?

July 21, 2019July 29, 2019

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

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

New CMS Rules to Increase Transparency and Lower Drug Costs

June 29, 2019June 30, 2019

The Centers for Medicare and Medicaid Services (CMS) recently published a final rule intended to increase transparency and lower drug prices. This announcement has been in the works since CMS first posted their proposal in November 2018. Now that the final ruling has arrived, it’s important for health plans to understand what’s changed and how the rule may affect their business. Tier 1 is available to consult with health plans about these important updates. In the meantime, here’s a brief look at what this final rule means for health plans and the health care industry more generally.

What Does the Final Rule Mean for Your Health Plan?

If you’ve been following along with this blog, this topic will already be familiar to you—we’ve been keeping you posted about its various updates since the proposal was first announced. Published on May 23, the CMS’s final rule is formally entitled, “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses.” As the title suggests, the amendments within the final rule pertain to both Part C (Medicare Advantage program) and Part D (Prescription Drug Benefit program) regulations. The amendments aim to help health plans negotiate for lower drug prices and reduce out-of-pocket costs for enrollees of Part C and Part D programs. The CMS ruling achieves this aim by improving regulatory frameworks and facilitating the development of products that meet patient needs while also reducing their fees. Health plans only want the best for their members—and reducing patients’ out of pocket costs help minimize the expenditures of Part C and Part D programs.

What Does the Final Rule Say that Your Health Plan Needs to Know?

On the same day they published their final rule, CMS posted a helpful fact-sheet outlining significant changes that your health plan needs to consider moving forward. Key takeaways include:

Part D policy relating to six classes of drugs has now been codified.
Part D plans are now required to adopt one or more electronic Real Time Benefit Tools that have the capability to inform prescribers when lower-cost therapies are available under their drug benefit.
Policy is now being finalized that would allow Medicare Advantage plans to implement step therapy for Part B drugs as a recognized utilization management tool.
CMS will now require Part D plans to inform members of drug price increases and lower-cost therapeutic alternatives in their Explanation of Benefits.
A new prohibition against gag clauses in pharmacy contracts now restricts Part D sponsors from prohibiting or penalizing a pharmacy from disclosing a lower cash price to an enrollee.

About Tier 1

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

The Biggest Takeaways from CMS’s Annual Spring Conference

June 28, 2019

This spring, the Centers for Medicare and Medicaid Services (CMS) held an event that you and your health plan will want to know about. Each year, CMS’s annual Medicare Advantage & Prescription Drug Plan Conference provides important information to health plan provider staff, management, and executives regarding updates to existing Medicare policies, technology, and much more. This year proved to be no different—and we want to share with you some key updates that may impact you and your business now and into the future.

The one-day conference provided a number of important takeaways regarding All Payer Policies, Medicare Advantage Qualifying Payment Arrangement Incentives (MAQI), eMedicare, and more. Below, we outline two topics that we believe will have a significant impact on you and your health plan.

Medicare Advantage Value Based Insurance Design Update

In order to succeed in the health care space, health plans must shape their priorities based on the most up-to-date information available to them. CMS’s spring conference offered the opportunity to not just receive the latest news, but to peer into the future and prepare for what’s to come in the industry over next several years. Of particular interest was CMS’s overview of the future of its Value Based Insurance Design model. Starting in 2020, this model will begin incorporating significant innovations, from allowing health plans and other organizations to design targeted benefits for enrollees based on chronic condition or socioeconomic characteristics to providing meaningful rewards and incentive programs. In 2021, CMS will be testing the possibility of adding a Medicare hospice benefit to this program as well. CMS’s stated goal is to promote patient-centered care and increase access through innovative means. We are certainly excited about these what these future benefits might mean for our health plan clients.

Medicare-Medicaid Integration Policies

One of the great benefits of CMS’s annual conference is the clarity experts provide on some of the most complex policies and rules that health plans must abide by. A panel dedicated to explaining new integration related to Parts C and D Rules for Dual-Eligible Special Needs Plans (D-SNPs) provided several valuable takeaways. These Rules address both policy and technical changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Program of All-Inclusive Care for the Elderly (PASE), Medicaid Fee-for-Service, and Medicaid Managed Care Programs for 2020 and 2021. This session highlighted important contexts for making updates to the regulations, specific regulation changes, and various operational considerations.

About Tier 1

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

CMS proposals to Medicare Part D address skyrocketing prescription drug costs

January 31, 2019

Prescription drug costs are a huge concern for Americans of all ages, especially those age 50 and older. A 2016 AARP survey of nearly 2,000 people found that 81 percent of older patients believe drug prices are too high. Nine out of 10 want the government to address the problem.

At the same time, a Bloomberg survey of 3,000 brand name prescription drugs determined that prices had doubled in some cases – and even and quadrupled in others – since December 2014.

The Centers for Medicare and Medicaid Services has released proposals to help contain prices in the Part D prescription drug benefit (and Medicare Advantage plans, but we only will cover Part D in this article). The hope is that the recommendations will offer health plans and pharmacies some flexibility as they try to help patients who often need expensive drugs to survive.

The complete CMS document is 185 pages long. Here are a few highlights that impact Part D plans.

– Part D policy requires plan sponsors to include on their formularies all drugs in six “protected” therapeutic classes: antidepressants, antipsychotics, anticonvulsants, immunosuppressants for treatment of transplant rejection, antiretrovirals and antineoplastics. The proposal would create three exceptions that would allow Part D sponsors to impose formulary actions on drugs in protected classes: prior authorization and step therapy; a protected class single source drug or biological if its WAC has increased; and a new formulation of a single source protected class drug or biological that has the same active ingredient as the original.

– The CMS proposal would allow plan sponsors to remove a Protected Class drug from their formulary if the drug price is too high. The idea is to give plans an opportunity to receive bigger rebates on those drugs, which until now have seen lower rebates than non-PC drugs. That would boost price competition and help keep costs low.

– CMS also is proposing changing the definition of negotiated price so that it reflects the minimum price available. That way, a pharmacy could be reimbursed for any drug. Before, pharmacies could receive additional reimbursements to lower drug costs based on performance. The reimbursements are determined at the end of the end of a coverage year. The problem is, the majority of pharmacies don’t quality for the reimbursements.

– Under the proposals, plan sponsors and pharmacy benefit managers could use pricing tables based on the lowest possible reimbursement in their claims processing systems that interface with contracted pharmacies. That way, pharmacies could create stronger, more accurate budgets based on projected revenues.

The new CMS proposals are beneficial for pharmacies, plans and patients. But they can be difficult and time-consuming for busy health plans to wade through and implement. Tier 1 Pharmacy Consulting can handle it all for you.

How? Our experience is rooted in clinical practice and evidence-based medicine. We can help your plan develop effective, proactive initiatives – including complicated CMS changes to prescription drugs and everything else – that lead to quality health outcomes for your members.

Working with Tier 1 also will improve your plan’s performance and ensure compliance to prevent a CMS audit (although we provide extensive audit guidance and support as well).

We also can help monitor and assess the initiatives delegated to your PBM to ensure you are receiving the right type of ROI.

About Tier 1

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

Opioid epidemic a CMS priority in 2019

January 29, 2019

At least 130 people a day die of an opioid overdose in the U.S., according to the Centers for Disease Control and Prevention.

In 2017, fatal opioid overdoses were six times higher than they were in 1999. More than 191 million opioid prescriptions – including Oxycodone, Hydrocodone and Methadone – were dispensed to patients across the country that same year, the CDC reports.

“To reverse this epidemic, we need to improve the way we treat pain,” the agency’s website says. “We must prevent abuse, addiction and overdose before they start.”

Older Americans are not immune to the dangers of opioid misuse. Millions of men and women over the age of 65 are filling prescriptions for many different opioid medications at the same time, the Agency for Healthcare Research and Quality has found. Many of them are hospitalized to treat opioid-related complications.

The statistics are startling. It comes as no surprise, then, that the Centers for Medicare and Medicaid Services announced that it has issued major changes to its 2019 Medicare Part D Opioid Prescribing Policies. The changes target Medicare patients of all kinds who have been given opioids – first-timers, chronic users, users with the potential to mix medications and high-risk users who are prone to addiction.

As these new opioid safety alerts are implemented, ongoing communication between pharmacists, Part D plans and prescribers is crucial. Health plans with pharmacy benefits should take note of the following changes.

Seven-day Supply Limit for New Patients

Medicare Part D patients prescribed opioids for the first time will now be limited to a seven-day supply or less. If more is needed, the provider must request a coverage determination on behalf of the member. This new rule does not apply to patients already taking prescription opioids.

Opioid Care Coordination Alert

Whenever a Medicare patient whose cumulative morphine milligram equivalent is 90 or above gives a pharmacist a prescription for opioids, an alert will go out to the prescriber. The pharmacist may consult with the doctor about the patient’s need for a high MME. The idea is to address the potential for danger yet keep the doctor-patient relationship positively intact.

Drug Management

Under the new guidelines, part D plans will be required to contact doctors treating Medicare patients identified as high-risk for abuse to evaluate whether the medication is safe, medically necessary, and if the risk for misuse is there. The plan representative also will ask the provider if a Part D drug management tool is appropriate, such as a POS claim edit, pharmacy lock-in or prescriber limitation.

The Bottom Line

Health plans should be ready to implement the changes and contact providers as needed. We must work together to address to stop the opioid epidemic, and that includes properly caring for our Medicare recipients. Tier 1 Pharmacy Consulting can help you navigate it all.

Visit the Centers for Medicare and Medicaid Services for more information on its new opioid safety guidelines.

About Tier 1

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

Is Your Website up to CMS Standards? If Not, We Can Help

January 29, 2019January 11, 2019

The ongoing requirements and regulations imposed by the Centers for Medicare and Medicaid Services can create an administrative headache for health plans who already have a laundry list of things to accomplish every day.

All marketing materials – including a health plan’s website – must comply with CMS guidelines that are often confusing, extensive and time-consuming.

Here is an overview and reminder of the general website requirements CMS has issued for Plan/Part D sponsors. We’ll tackle social media and mobile rules in a future post, because there are rules there, too.

Tier 1 Pharmacy Consultants can help you update your website and ensure all of your marketing materials are CMS compliant.

What Health Plans Must Do

Build a website that is easy to understand and navigate.
Maintain the current website content through Dec. 31 of each year.
Notify visitors if there is a link that will take them to a non-Medicare information webpage or to a different website altogether.
Include applicable disclaimers on every page of the site.
Build a separate section for Medicare information covered by the guidelines if the health plan also markets other lines of business.
Review and update website content as needed, including ever-changing prescription drug prices and information.
Include the date of the last update on each page.
Label all links.
Comply with Section 508 of the federal Rehabilitation Act, which requires agencies to make their electronic and information technology comply with the Americans with Disabilities Act, which prohibits discrimination against people with disabilities.

Document Requirements

Health plans also are required to post a handful of downloadable documents, such as marketing materials and communication materials. The documents must be accurate and up-to-date at all times.

Some documents, such as the Summary of Benefits, Annual Notice of Change, Evidence of Coverage, Provider Directory, and Formulary all needed to be in place by Oct. 15 of last year. Others needed to be posted all year and had Jan. 1 deadline for updates.

The Privacy Notice under the HIPAA Privacy Rule; Exception Request Forms for Physicians; Utilization Management Forms for Physicians and Enrollees; the Prescription Drug Transition Policy; Prior Authorization Forms for Physicians and Enrollees; and Part D Model Coverage and Redetermination Request Forms needed to be post on a plan’s website by New Year’s Day.

If it was a struggle, we can make it easier next time around.

What Health Plan Websites Can’t Do

Just like there are rules outlining what plans must do, CMS also has put forth actions they are prohibited from doing, including:

Plans cannot link to foreign drug sales, including links from advertisements, on their websites.
Plans cannot instruct users to input personal information other than a zip code, county, and/or state for access to non-beneficiary specific website content.
Plans cannot claim that they are not responsible for the content of their social media pages, as well as the websites of any related party that provides information on the plan’s behalf, such as a public relations representative or social media specialist.

Plans Cannot Forget to Include

A toll-free customer service number, days and hours of operation and TTY number address.
Member rights and responsibilities upon disenrollment.
Instructions on how to appoint a representative along with a link to the downloadable version of the CMS Appointment of Representative Form.
Instructions on how to file a grievance and an appeal, including procedures for filing, a link to the webpage, the 1-800 MEDICARE number, mailing address, fax number, any forms created by the health plan for appeals and grievances and more.
The statement, “You must file Form 1040, ‘US Individual Income Tax Return,’ along with Form 8853, ‘Archer MSA and Long-Term Care Insurance Contracts’ with the Internal Revenue Service (IRS) for any distributions made from your Medicare MSA account to ensure you aren’t taxed on your MSA account withdrawals. You must file these tax forms for any year in which an MSA account withdrawal is made, even if you have no taxable income or other reason for filing a Form 1040. MSA account withdrawals for qualified medical expenses are tax free, while account withdrawals for non-medical expenses are subject to both income tax and a fifty (50) percent tax penalty.”
The statement, “Tax publications are available on the IRS website at http://www.irs.gov or from 1-800-TAX-FORM (1-800-829-3676).”
Enrollment instructions and forms.
Medication Therapy Management program requirements.

Remember, CMS has the right to directly enforce its provisions to ensure compliance. Don’t let it get to that point. Make sure your website is up to par.

How we can help

The team at Tier 1 Pharmacy Consulting can be the liaison between the health plan and the pharmacy benefit manager to help oversee the steps needed to ensure CMS compliance, including regular website updates. The Tier 1 team can offer solutions on how to properly and effectively institute the appropriate process for oversight and ensure health plan information and marketing is compliant, accurate and up-to-date all year.

We are experts in Medicare. Even the best health plans need CMS guidance. That’s why we’re here.

About Tier 1

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

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

January 29, 2019December 26, 2018

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

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

January 19, 2019October 16, 2018

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

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

Don’t Forget: The Medicare Provider and Pharmacy Deadline is Oct. 15

January 19, 2019October 2, 2018

Is your health plan’s Medicare Provider and Pharmacy Directory up-to-date? If not, keep reading.

The federal Centers for Medicare and Medicaid Services requires health plans to provide their members with a Provider and Pharmacy Directory, both print and online. That way, when men and women enroll in Medicare they have immediate access to lists of providers and pharmacies.

Current and ongoing Medicare beneficiaries are entitled to a new directory if they need one.

As time goes on and plans, provider and pharmacies change, CMS requires plans to ensure their directories are accurate and updated every year. The deadline this year is October 15th.

The task is more challenging than it seems. In addition to including new and/or different providers and pharmacies, health plans should, among other things:

Include an index of all providers and pharmacies
Make sure their online directories contain the same information CMS requires for print directories
Ensure that when plans are made aware of a change that their directories are updated within 30 days.
Make their online and print directories easy to read and understand
Ensure phone numbers are toll-free and include a toll-free TTY/TDD number and days and hours of operation
Include language as indicated in CMS instructions throughout the directory
Include a link on printed materials for members to go online if desired
Include general pharmacy information after general provider information and before provider listing requirements begin
Make sure copy in the directories is written in a way that complies with suggested reading levels
Format directories to make information easy for both English speaking and non-English speaking beneficiaries to read and understand whenever possible
Format sections, charts, tables and text to fit on a single page, or enter a blank return before right aligning with clear indication that the item continues to the next page. For example: (This section is continued on the next page)
Break up large blocks of plan-customized text into short paragraphs or bulleted lists and give a couple of plan-specific examples
Spell out an acronym or abbreviation before its first use in a document or on a page; i.e., low income subsidy (LIS)
Use universal symbols and/or commonly-understood pictorials
Consider using regionally appropriate terms or common dialects
Consider producing translated models in large print
If desired, provide subdirectories by specialty or geographic area to enrollees if it states that the complete directory will be provided to enrollees upon request. Subdirectories must be consistent with requirements outlined in the Medicare Managed Care Manual, the Medicare Prescription Drug Benefit Manual and the Provider and Pharmacy Directories Requirements subsection in the introduction to each state’s specific marketing guidance.

And that’s just a handful of the rules and guidelines required for the guide. You also need to make sure it’s been proofread and is grammatically correct.

It’s a huge undertaking. Many health plans don’t have the time or the right personnel in place to handle the huge task of updating the guide, especially when it comes to the pharmacy portion.

Tier 1 Pharmacy Consulting can help. We are experts in the Medicare Provider and Pharmacy Directory as well as overall Medicare marketing regulations and policy writing. We can interpret the CMS model document and use the right variables to customize it to health plans so that it is correct and remains within the right framework.

Tier 1 can help you stay compliant at all times, so you can focus on running your health plan.

About Tier 1

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