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Medicare Part D Study Results on Access to Preferred Cost Sharing Pharmacies

The Centers for Medicare & Medicaid Services (CMS) announced in the CY2015 Call Letter various concerns surrounding beneficiary access to retail network pharmacies offering preferred cost sharing. CMS has found that some plans provide very limited access to preferred cost sharing; for instance, they found one plan that offered preferred cost sharing at only seven pharmacies in a PDP region. CMS has also heard concerns about access to preferred cost sharing from beneficiaries, particularly in rural areas, and a number of pharmacy trade groups have complained that retail pharmacies have not been given the opportunity to accept the terms necessary to offer preferred cost sharing.

CMS is concerned that offers of preferred cost sharing may be influencing beneficiaries to enroll in plans in which they do not have meaningful and/or convenient access to preferred cost sharing. This may have the effect of misleading or otherwise making material misrepresentations to beneficiaries and could be a violation of our marketing requirements.

Although CMS is not adopting any network adequacy standards at this time, sponsors should be aware that they are continuing to monitor beneficiary access to preferred cost sharing in plans that purport to offer preferred cost sharing. For the 2014 and 2015 plan years, CMS will continue to review the retail networks of plans offering preferred cost sharing and will continue to take appropriate action regarding any plan whose network of pharmacies offering preferred cost sharing appears to offer too little meaningful access to the preferred cost sharing. Plans may be asked to increase the number of pharmacies offering preferred cost sharing or to restructure its benefit design during the bid negotiation process. The intent of these negotiations will be to ensure that beneficiaries are not misled into enrolling in a plan only to discover that they do not have meaningful access to the advertised lower cost sharing.

To further analyze this issue, CMS had awarded a contract to study this topic. CMS has completed this study on Preferred Cost Sharing Pharmacy and will present its findings to the industry and other interested parties via Webinars on December 16 and December 17, 2014.

Webinar Session 1:

When: Tuesday, December 16, 2014

Time: Phone lines open at 2:45 Eastern Time (ET) and webinar begins at 3:00PM and ends at 4:30PM ET

Webinar URL: https://webinar.cms.hhs.gov/pcsp1/

Dial-in number: 1-877-267-1577

Meeting Number: 998 213 241

Webinar Session 2:

When: Wednesday, December 17, 2014

Time: Phone lines open at 2:45 Eastern Time (ET) and webinar begins at 3:00PM and ends at 4:30PM ET

Webinar URL: https://webinar.cms.hhs.gov/pcsp2/

Dial-in number: 1-877-267-1577

Meeting Number: 998 213 241

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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