Pharmacy benefit consulting Archives • Page 2 of 2 • Tier 1 Pharmacy Consulting

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

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.

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.

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.

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

January 19, 2019October 2, 2018

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

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