medicare

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

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 

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.

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

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 

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.

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

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.

The Medicare Plan Finder: When Drug Prices are Wrong, Consumers Lose

Medicare’s Plan Finder remains the best consumer tool to search for a Medicare Part D and Medicare Advantage Plan. The government wants to keep it that way.

Plan Finder lists all of the health plans available in a person’s zip code and includes 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 to make informed decisions about what kind of health and pharmacy care plan they need – and how much they can afford.

But Plan Finder is only as accurate – or as useful – as the information it receives. 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.

During the active months, 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.

Why? Because 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. .

Let’s say a drug on the Medicare Plan Finder for your health plan is shown to cost  $4, but when CMS retrospectively reviews a claim for that drug they see that the member paid$10. This discrepancy can negatively impact your plan performance when it comes to the measure of accuracy of the Plan Finder information, not to mention the potential for member grievances with a cost discrepancy like this.

Here’s what CMS wants plans to do:

  • Ensure timely and accurate CY 2018 pricing data for posting on Medicare’s Plan Finder.
  • Identify preferred cost-sharing pharmacy arrangements in the Plan Finder pricing files.
  • Confirm pricing and pharmacy network data files for the Plan Finder are up-to-date, correct and accurate, and that only pharmacies under contract are included in the tool. Incorrect data may result in suppression from the Plan Finder tool, as well as appropriate compliance actions.
  • Establish a routine process for sampling a subset of drugs and comparing the pricing on the Plan Finder site versus what is being adjudicated by your PBM at the pharmacy counter.
  • Evaluate your Plan Finder accuracy ratings report available for your plan to identify any potential areas of improvement.

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

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.