CMS Draft Call Letter Released; Opioid Use Worrisome

Opioids remain a concern for officials at the Centers for Medicare and Medicaid Services (CMS). The agency has announced that addressing the epidemic – addiction, misuse, overdose and death – is one of its top priorities, and that officials have made big changes to 2019 Medicare Part D Opioid Prescribing Policies as a result.

More recently, CMS included in its Medicare Advantage (MA) and Part D draft call letter for 2020 a proposal to implement provisions of the federal SUPPORT for Patients and Communities Act that that require coverage of opioid addiction treatment programs, including medication-assisted treatment. The letter also encourages health plans to lower the out-of-pocket cost of Naloxone, which can quickly treat a narcotic overdose in an emergency, and, just as importantly, encourage doctors to prescribe the drug alongside opioids just in case. Alternative therapies also are encouraged. CMS says it plans to increase surveillance of opioid misuse with its overuse and misuse monitoring system.

The final version of the call letter will be released in early April. The initial draft also includes:

Changes to Supplemental Benefits

CMS is proposing that Medicare Advantage plans offer supplemental benefits outside the primary health plan to patients that suffer from a chronic illness. Those benefits would include things like transportation to and from medical appointments and other help.

Changes to Star Ratings

CMS wants opioid and benzodiazepine misuse measures included in the star ratings for MA plans. The idea is to track use and prevent prescriptions being handed over from several providers to patients who have developed an addition – or at the very least are misusing the drug.

Generic and Brand Formulary Tiers

CMS is looking at provisions that would prevent Part D plan formulary tiers from including both generic and brand formularies. Instead, generics and brands would be kept separate.

CMS changes can be difficult to navigate and keep track of. Need help? That’s why we’re here. The team at Tier 1 Pharmacy Consulting are pharmacy benefit plan experts, providing support and consultation for all types of CMS changes. Remember, plans that fail to abide will be subject to a CMS audit.  Agency officials are watching health plans very closely this year.

Tier 1 can review changes to ensure accuracy and compliance. In the event of an audit, we will interpret data to identify potential issues, craft responses and create corrective action plans.

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.

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