Keeping up the heat on Medicare “Preferred Pharmacy” Access

By Kevin Schweers

To better inform patients and caregivers, Medicare officials are preparing “disclaimer language” to accompany marketing material for any Medicare Part D drug plans that fail to offer convenient access to discounted copays at “preferred pharmacies.” The move comes in response to concerns expressed repeatedly by NCPA and others regarding inadequate patient access and exclusionary “preferred” networks.

In response to complaints by NCPA and others, the Centers for Medicare & Medicaid Services (CMS) analyzed drug plans’ “preferred pharmacy” networks. CMS found that over half of the plans failed to meet the government’s standard for pharmacy access in urban areas. Better disclosure by plan sponsors is part of CMS’ efforts to help prevent beneficiaries from any “bait and switch” situation whereby they may sign up for attractive copays that in reality they cannot practically access.

Here is CMS’ current draft disclaimer language:

“(insert organization/plan name’)s pharmacy network offers significantly limited access to pharmacies that provide preferred cost sharing in area(s). For updated information about our network pharmacies, including those that offer preferred cost sharing, please call or consult the online pharmacy directory at (insert website).”

In disseminating that draft disclaimer CMS renewed its concerns, shared by NCPA, about insufficient access and misleading marketing. The agency wrote, “CMS is concerned that beneficiaries residing in areas with limited access to [‘preferred pharmacies’] may be unable to obtain the lower cost sharing advertised in plan materials. We believe this may make marketing materials misleading or otherwise misrepresentative of available cost sharing to beneficiaries in violation of our marketing requirements.”

NCPA is preparing comments to CMS on this draft disclaimer with recommendations to make it most impactful. Hopefully steps like this can at least partially reduce the mass confusion and disruption that affects Medicare beneficiaries and their community pharmacists at the start of each plan year in January.

Of course the ultimate solution that NCPA continues to advocate is implementation of an “any willing pharmacy” policy to allow patients to use a convenient pharmacy that agrees to the drug plan’s “preferred pharmacy” terms and conditions.

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