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

May 26, 2019May 27, 2019

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?

May 14, 2019

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

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

CMS proposes updates to audit Civil Monetary Penalties

March 28, 2019March 29, 2019

Medicare plans and pharmacy teams are being heavily scrutinized by the Centers for Medicare and Medicaid Services – now more than ever before. The changes CMS has implemented for 2019 as well as upcoming proposed changes for the next few years suggest that plans are more likely to be audited than not.

An audit is certainly a black mark on a health plan. It’s stressful. And, it can be expensive.

CMS audit penalties have cost health plans as much as $375,000. In mid-March, the agency released a proposal updating its civil monetary penalty listings for last year’s audits – and the fines are all higher per enrollee. An overview:

Per Enrollee Penalty Amounts in 2017 and 2018

– Standard Penalty: $200

– Aggravating Factors: $100

– Untimely/Inaccurate Beneficiary Communications Standard Penalty: $25

– Untimely/Inaccurate Beneficiary Communications Aggravating Factor: $15

Penalty Amounts for 2019-2021

– Standard Penalty: $212

– Aggravating Factors: $106

– Untimely/Inaccurate Beneficiary Communications Standard Penalty: $27

– Untimely/Inaccurate Beneficiary Communications Aggravating Factor: $16

Why is CMS raising the fines? That remains to be seen. Among other things, officials take into account inflation and cost-of-living adjustments.

CMS plans to release a final plan in April.

Audits are usually conducted once every between three to five years. There are different types, including 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.

It’s important to be ready at all times for an audit – especially if your health plan has performance issues or has faced CMS oversight in the past.

Plans that do not have a vigorous auditing and monitoring program are at risk of non-compliance with CMS regulations – and resulting fines. Being prepared will help plans identify and respond to potential gaps and address them as quickly as possible. The audit process is extensive, and tough to do when you’re trying to run your plan every day. And, don’t forget, plans only have three weeks from the time they receive an audit notice to be ready for it to get underway. You’re going to need help – and that’s where we come in.

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.

Get in touch today – before an audit notice lands on your doorstep and costs your plan hundreds of thousands of dollars or more.

About Tier 1

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

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

March 11, 2019March 11, 2019

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

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.

CMS Changes to 2019 Audit Protocol: What You Need to Know

January 19, 2019January 21, 2019

Pharmacy teams can now expect their drug management programs to fall under considerable audit scrutiny by the Centers for Medicare and Medicaid Services regarding a new federal law that aims to prevent prescription opioid misuse and addiction.

For the first time, CMS will look at health plans’ implementation of the Comprehensive Addiction and Recovery Act throughout the program audit process.

The agency released the change as part of its 2019 audit protocols.

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 are increasingly subject to closer CMS monitoring and review. An audit is more likely now than ever before.

Be Prepared

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.

The next audit notifications will be sent between March and July.

Fewer Deliverables

The CMS changes to audit protocols include some positive news for health plans – including a reduction in audit deliverables. For example, health plans are no longer required to submit Call Logs and answers to supplemental questions during a program audit. CMS has suspended:

The collection of CDAG, ODAG, and SARAG Supplemental Questions at the time an audit engagement letter is drafted. Instead, CMS is encouraging plans to use the questions as a guide to determine non-compliance.
The collection of 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.
The collection of certain CPE data and documentation that can be obtained elsewhere.
The collection of Formulary and Benefit Administration and Special Needs Model Plan of Care enrollment verification evaluation.

CMS also has decided to make three CPE universe data fields optional: CPE FTEAM Column C, FTE Contract Effective Date; and CPE ECT Columns I and J, “Medicare Compliance Department Employee” and “Compliance Department Job Description.” The agency determined each played an insignificant role in determining non-compliance.

CMS also says it will take a broader look into the misclassification of calls as well as compliance and oversight of call routing.

The Bottom Line

Many of the changes for 2019 will reduce the burden on health plans. Others are challenging. Plans should take steps to address the changes and plan for an audit that is likely coming – this year or down the road. We can help.

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.

What Are Your Health Plan’s New Year’s Resolutions?

January 19, 2019January 2, 2019

Studies for years have shown that more than half of Americans make financial resolutions in the New Year. (Not surprisingly, the other half vow to lose weight.)

New Year’s Resolutions often include business goals. Building efficiency, saving money and increasing value should be at the top of every company’s list for 2019 – including health plans that offer prescription drug benefits.

That’s why it’s smart for busy health plans to team up with an expert who can help them reach their goals.

The team at Tier 1 Pharmacy Consulting offers benefit consulting services for health plans of all sizes to increase their capabilities, cut costs and improve the services they provide for members. We are an authority in Medicare governance and compliance so we can help plans that are already stretched thin ensure they are meeting regulations and avoid Centers for Medicare and Medicaid Services (CMS) audits and other problems that could otherwise arise.

For example, Medicare Advantage enrollees will have from now until March 31 to choose the health plan that is right for them, according to the CMS. That period had previously ended more than a month earlier, on Feb. 14. CMS also has reversed its rule prohibiting formulary design that would expand prescription drug choices for Part D health plans and their members.

Both of these are good things, but are you ready? There is a lot to do first; most health plans don’t have the time, resources or experts on staff that can ensure accuracy.

We can help.

Even though we opened our doors just this year, our founder is a clinical pharmacist with more than a decade of pharmacy benefit management experience. We collaborate and advise our clients so the pharmacy benefits they provide are stronger, always compliant and more cost-effective than ever before.

If you’re new to us, here’s a bigger overview of what Tier 1 can do for your health plan. Click on each link for more information. Many health plans need at least one – if not all – of these series.

We want to help you reach your 2019 health plan resolutions. Contact us today.

Happy New Year!

About Tier 1

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

The truth is, 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.

Take a look at what we can do for you.

We are here to help. Let’s talk about how we can be there for your health plan. Want to learn more? Email us at info@tieronepc.com.

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.