prescription drugs

New CMS Rules to Increase Transparency and Lower Drug Costs

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 

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.

The Biggest Takeaways from CMS’s Annual Spring Conference

This spring, the Centers for Medicare and Medicaid Services (CMS) held an event that you and your health plan will want to know about. Each year, CMS’s annual Medicare Advantage & Prescription Drug Plan Conference provides important information to health plan provider staff, management, and executives regarding updates to existing Medicare policies, technology, and much more. This year proved to be no different—and we want to share with you some key updates that may impact you and your business now and into the future.

The one-day conference provided a number of important takeaways regarding All Payer Policies, Medicare Advantage Qualifying Payment Arrangement Incentives (MAQI), eMedicare, and more. Below, we outline two topics that we believe will have a significant impact on you and your health plan.

Medicare Advantage Value Based Insurance Design Update

In order to succeed in the health care space, health plans must shape their priorities based on the most up-to-date information available to them. CMS’s spring conference offered the opportunity to not just receive the latest news, but to peer into the future and prepare for what’s to come in the industry over next several years. Of particular interest was CMS’s overview of the future of its Value Based Insurance Design model. Starting in 2020, this model will begin incorporating significant innovations, from allowing health plans and other organizations to design targeted benefits for enrollees based on chronic condition or socioeconomic characteristics to providing meaningful rewards and incentive programs. In 2021, CMS will be testing the possibility of adding a Medicare hospice benefit to this program as well. CMS’s stated goal is to promote patient-centered care and increase access through innovative means. We are certainly excited about these what these future benefits might mean for our health plan clients.

Medicare-Medicaid Integration Policies

One of the great benefits of CMS’s annual conference is the clarity experts provide on some of the most complex policies and rules that health plans must abide by. A panel dedicated to explaining new integration related to Parts C and D Rules for Dual-Eligible Special Needs Plans (D-SNPs) provided several valuable takeaways. These Rules address both policy and technical changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Program of All-Inclusive Care for the Elderly (PASE), Medicaid Fee-for-Service, and Medicaid Managed Care Programs for 2020 and 2021. This session highlighted important contexts for making updates to the regulations, specific regulation changes, and various operational considerations.

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.

HHS proposes removing safe harbor for drug rebates

Prescription drug prices have risen every year for nearly a decade at rates that are higher than the U.S. inflation rate.

The costs of brand name oral drugs nearly doubled between 2008 and 2016, according to an ABC news report earlier this year. The increase was five times that of the inflation rate.

Generic oral medications saw a smaller increase – yet it was still double the rate of inflation. Specialty medications rose 13 times faster than inflation during the same period.

OIG Proposal

A few weeks after this and similar news stories broke, the U.S. Department of Health and Human Services issued a proposal to remove drug rebates for PBMs. Under the umbrella of the federal Anti-Kickback statute, the HHS Office of Inspector General said the move could ban rebates ­on brand-name prescriptions, which benefit drug sellers, and protect discounts and services that benefit patients.

The proposed change “may curb list price increases, reduce financial burdens on beneficiaries, lower or increase federal expenditures, remove transparency and reduce the likelihood that rebates would serve to inappropriately induce business payable by Medicare Part D and Medicaid MCOs (managed care organizations),” the OIG’s office wrote.

At the same time, the government is also proposing a new safe harbor to protect point-of-sale discounts that drug manufacturers provide directly to patients. HHS also wants s a second new safe harbor to protect certain administrative fees paid by manufacturers to pharmacy benefit managers.

The proposals are in direct response to skyrocketing drug costs. Proponents worry that some patients are not receiving life-saving drugs because they can’t afford them. Pharmacy benefit managers help health plans manage costs and drug utilization. They do that by negotiating with manufacturers and pharmacies to facilitate beneficiary access to appropriate medications, while managing the costs to the plan.

Even so, according to HHS data, the changes could lower beneficiary out-of-pocket costs. Varying from patient to patient, the proposals if implemented could result in higher premiums. That’s something to keep in mind.

Background

The Anti-Kickback Statute is part of the Social Security Act of 1972. Amended five years later, it made it a crime to receive money or rewards for services offered by Medicare or another federal healthcare program.

Meanwhile, the Ant-Kickback “Safe Harbors” statute of 1987 exempts certain transactions from penalties. They include bona fide employment relationship, personal service arrangements, lease or rental of office space or equipment, referral services and a few more.

HHS makes clear it does not intend to remove protection from rebates required by law, such as rebates under the Medicaid drug rebate program. HHS also intends for protection to continue for drug discounts offered to entities such as wholesalers, hospitals, physicians, pharmacies, and third-party payors in other federal health care programs.

The agency is soliciting comments on whether the proposed amendments to the safe harbor regulation would exclude from protection any price reductions “not contemplated by the proposed amendment.”

The effective date of the proposed update to the safe harbor regulation would be Jan. 1 of next 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.

Drop us a note at info@tieronepc.com. Let’s get connected.

CMS proposals to Medicare Part D address skyrocketing prescription drug costs

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 

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.

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.

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.