CMS Warns Medicare Drug Plans on Patients’ Pharmacy Choice


By Kevin Schweers

The Centers for Medicare & Medicaid Services (CMS) is rightly taking action to help prevent patients from being steered away from their pharmacy of choice and into a mail order pharmacy program.

NCPA strongly supports such efforts by CMS. Beneficiary rights and choice of pharmacy should not be infringed upon by Medicare Part D plan sponsors or their contracted pharmacy benefit managers, or PBMs (with a financial interest in growing their proprietary mail order business).

At issue is what’s known as CMS’ “model transfer guidance.” Essentially it’s a protocol Part D plans must follow to document a patient’s affirmative decision to switch from one pharmacy provider to another.

In December 2011, NCPA sent a letter to CMS to alert the agency to repeated reports of alleged actions by plan sponsors that appeared to violate the model transfer guidance. These included complaints of inappropriate transfers to mail order without the patient’s consent.

NCPA’s letter argued that, despite the model transfer requirements, “we have learned that a number of part D plans across the country are calling and harassing beneficiaries to transfer their prescriptions to a preferred network pharmacy (most commonly a mail order pharmacy). These plans repeatedly call beneficiaries to make the change. Some plans are even moving patients to mail order without telling them, such that the patient fills a prescription at their community pharmacy and receives a duplicate prescription in the mail.”

In light of such needless spending, attached to the NCPA letter to CMS was a copy of NCPA’s presentation on mail order waste, entitled “Waste Not, Want Not.”

On May 4th, CMS sent a notice to Part D plan sponsors reminding them of their obligations to protect patient choice of pharmacy.

“CMS has recently observed an increase in beneficiary complaints related to the transfer of prescriptions from retail pharmacies to either mail-order or specialty pharmacy without their explicit consent,” the agency said. “

This action by CMS is a step in the right direction. Hopefully, the agency continues to take this issue seriously and applies greater oversight in the future.

NCPA appreciates the attention CMS is bringing to these issues and will continue to work with the Part D program to ensure beneficiaries are not misled and their access is not hindered.

2 Responses to “CMS Warns Medicare Drug Plans on Patients’ Pharmacy Choice”


  1. 1 david snow ( im laughing all the way to then bank) May 19, 2012 at 12:07 pm

    why is cms warning drug plans and PBMS? if a indy pharmacy was doing something like this they would be knocking down the door trying to close them down or a nice hefty fine would be added. These warnings do really show the FAVORABLE BIAS towards PBMs,as even when they manipulate the market for improper gain, the govt gives them a slap on the wrist.
    Disgusted

    • 2 Bill pearson May 19, 2012 at 8:17 pm

      I am currently suffering from this situation. It was brought to my attention by a very loyal patient who was very irate. The letter that you have written is to mild. I know a situation where pharmacy law was violate by a PBM. It is every complex what they do.


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