CMS

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 

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.