CMS to scrutinize Part D plans with preferred cost-sharing pharmacies

The Centers for Medicare & Medicaid Services (CMS) intends to crack down on Medicare drug plans that steer seniors toward preferred networks that don't provide easy access to pharmacies, especially in urban areas.

The language appeared in the CMS proposal for 2016 Medicare Advantage rates. The agency detailed the results of an independent study of 641 Medicare Part D plans that include preferred cost- sharing pharmacies (PCSPs).

Only 46 percent of plans provide access to PCSPs in urban areas that meet the "convenient access standard" (meaning that 90 percent of beneficiaries live within two miles of a network retail pharmacy), compared to 87 percent for suburban areas (90 percent live within five miles) and 95 percent of rural areas (70 percent live within 15 miles).

"Based on this analysis, we are concerned that beneficiaries residing in areas of low access to PCSPs may be unable to obtain the lower cost sharing as advertised in plan materials," CMS wrote. "We believe this may make marketing material misleading or otherwise misrepresent available cost sharing to beneficiaries in violation of our marketing requirements."

CMS continues to scrutinize the adequacy of Medicare Part D preferred network plans, FierceHealthPayer previously reported. Last year, the Obama administration scrapped a proposal that would let Part D plans expand the number of pharmacies in their preferred networks, among other changes, amid criticism that the government didn't need to fix a Part D program that wasn't broken.

CMS does not plan to establish access standards for PCSPs, but the agency said it will take two steps to ensure that beneficiaries "are clearly informed of their options."

  • CMS will publish data on pharmacy-access levels for all plans that offer the preferred cost-sharing benefit structure.
  • During the bidding process, CMS will work with "outlier" Part D plans in the bottom 10 percent of any given geography so the plans can either increase access or stop marketing themselves as preferred cost-sharing plans "where the benefit is not meaningfully available."

PCSPs are increasingly popular among payers, according to Healthcare Payer News. While fewer than 10 percent of Medicare Part D stand-alone drug plans had preferred pharmacies in 2011, more than 85 percent did by 2015.

Payers must also be careful when making changes to preferred network plans. Last month, Aetna wrongly identified 5,500 in-network Part D pharmacies, an error that forced the insurer to give 400,000 beneficiaries access to its broadest network while they decided to either switch plans or find new pharmacies.

For more:
read the CMS proposal (.pdf), starting on pg. 148
here's the Healthcare Payer News article

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