health plan consulting Archives • Tier 1 Pharmacy Consulting

2020 Readiness Checklist for Medicare Advantage Organizations & Prescription Drug Plans

November 27, 2019

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Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program.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

November 15, 2019November 15, 2019

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

A four or five star rating is within your reach for 2021. 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.

CMS Announces 2018 Parts C and D Audit Report

October 2, 2019October 3, 2019

The Centers for Medicare and Medicaid Services (CMS) last month released the agency’s 2018 Medicare Part C and Part D Program Audit Report. Such reports can be challenging to navigate through, but it’s important that health plans understand them in the event they experience an audit.

Background

The Medicare Parts C and D Oversight and Enforcement Group (MOEG), a division of CMS, releases the report every year. It includes data from recent audits. The idea is to explain CMS initiatives and boost transparency of the entire auditing process. Program audits are conducted by MOEG to ensure Medicare Advantage and prescription drug plans are offering the right access to health care services and medications to enrolled seniors.

As CMS writes: “Regular and consistent auditing of these organizations…provides measurable benefits by:

• Ensuring enrollees have adequate access to health care services and medications; • Verifying sponsors’ adherence to selected aspects of their contract with CMS;

• Providing a forum to share audit results and trends; and

• Soliciting feedback from the sponsor community and external stakeholders on potential audit improvements.”

2018 Highlights

Changes to audit processes based on sponsor feedback. Among other things, CMS expanded technological capabilities and reduced the scope of data collection to make submissions more streamlined. It also extended the fieldwork phase from two weeks to three weeks, and made the audit validation and close-out process better.

Audit results. CMS reports lower overall audit scores between last year and the year before, from 1.10 in 2017 to 1.03 in 2018. Scores were lower in Part D Formulary and Benefit Administration (FA) and Part C Organization Determinations, Appeals and Grievances (ODAG). Average FA scores, though, showed improvement with a reduction of 62% in 2018.

Audit Enforcement. CMS imposed $396,736 in 10 CMPs. There were three intermediate sanctions against sponsors for non-compliance, but fewer CMPs imposed for 2018.

To view the full report, go here.

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. It’s important to be ready for an audit – especially if your health plan has performance issues. 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 compliance and get you through the process.

Get Started

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

CMS unveils new-and-improved Medicare Plan Finder

September 15, 2019September 16, 2019

Seniors will have an easier time shopping for health plans and drug coverage thanks to a major overhaul of one of the government’s key online services.

The Centers for Medicare & Medicaid Services last month unveiled a new-and-improved Medicare Plan Finder on the Medicare.gov website. The move is part of the government agency’s eMedicare initiative to create a modern, personalized, and seamless customer experience for Medicare recipients.

It’s the first time in a decade that CMS has made changes to the system, and the new plan finder and related technology facelift comes just ahead of annual open enrollment when seniors begin in October to choose their plans for 2020.

A Needed Makeover

The plan finder upgrades include:

– A more simple login process to Medicare recipients’ online accounts.

– A fast drug list builder that reviews recipients’ prescriptions over the previous 12 months and suggests generic alternatives to name-brand drugs.

– More details on the different Medicare Advantage plans so seniors can easily compare benefits and choose the plan that is right for them.

– A guide for seniors to compare original Medicare, supplemental policies and Medicare Advantage plans, as well as up to three drug plans or three Medicare Advantage plans side-by-side.

Why Now?

In July, the Government Accountability Office (GAO) in a study determined that the Medicare Plan Finder was challenging for beneficiaries to navigate. It also provided incomplete information and information that was tough to find and even tougher to understand.

The Medicare Plan Finder was created to provide all of the health plans available in a person’s zip code, with crucial information about premiums and out-of-pocket costs, particularly for prescription drugs. Pricing is different for every health plan, so the tool aims to help consumers make informed decisions about what kind of health and pharmacy care plan they need – and how much they can afford. Plan Finder drug prices are updated regularly from October through August. Pricing for the current year is frozen in September in preparation for the new plan year’s display.

Under the changes, the new Plan Finder makes choosing a plan much easier and more user friendly. It’s also a welcome change for health plans, who have spent time and money trying to improve their own networks to offer people over age 65 private Medicare Advantage coverage, according to Forbes. Experts predict enrollment in private Advantage plans could rise as high as 70 percent between 2030 and 2040. If all goes as expected, the now easy-to-use Plan Finder could boost Medicare Advantage enrollment even further.

“The new Plan Finder walks users through the Medicare Advantage and Part D enrollment process from start to finish and allows people to view and compare many of the supplemental benefits that Medicare Advantage plans offer,” CMS said in a statement.

What Health Plans Need to Do

To keep the Plan Finder information current, Medicare requires health plans to submit files that update the costs of prescription drugs every two weeks. Many plans delegate this function to their PBM, but it’s important that health plans stay engaged in this process and ensure that there are effective processes to oversight these frequent submissions. Medicare wants to make sure enrollees are provided the most accurate information when making the decision on what prescription drug plan works best for them.

If a health plan fails to update its prescription drug pricing and other information, it could be suspended or removed from the Medicare Plan Finder. The plan won’t show up when consumers do a search using the tool, so they won’t even know your health plan exists. That means less money going into your health plan and an overall loss of revenue over time.

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 updates to the Medicare Plan Finder. We can offer solutions on how to properly and effectively institute the appropriate process for oversight and ensure drug prices are, at all times, accurate and up-to-date all year. We are experts in Medicare. Avoid a Plan Finder suppression by partnering with us. We 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.

CMS Seeks Comments on Proposed Audit Protocol Changes for 2020

August 27, 2019August 27, 2019

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

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.

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?

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.

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 Draft Call Letter Released; Opioid Use Worrisome

March 25, 2019

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

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.