Improving Medicare Beneficiary Access to Preferred Cost-Sharing Pharmacies

To improve access for beneficiaries, CMS has proposed a plan to increase the availability of preferred cost-sharing pharmacies in Medicare.

To improve access for beneficiaries, CMS has proposed a plan to increase the availability of preferred cost-sharing pharmacies in Medicare.

Last year, CMS was concerned that some beneficiaries did not have ready geographic access to preferred cost-sharing pharmacies. Add to that, Medicare Part D plans are creating smaller networks of pharmacies within their larger networks and offering lower cost-sharing arrangements to beneficiaries who use these preferred cost-sharing pharmacies.

While such lower cost-sharing arrangements seemed lucrative to the beneficiaries who wished to save money on their prescription drugs, in most instances, it wasn’t ideal because the pharmacies were not geographically accessible to the beneficiaries in the plan.

Bridging Geographical Gaps

CMS published an analysis of the availability of preferred cost-sharing pharmacies to Part D enrollees in April 2015. The report highlighted that most Part D enrollees lived in areas with accessibility to a robust preferred cost-sharing pharmacy network. However, the report also stressed on a shortcoming—a few beneficiaries, especially those living in urban areas, face limited or no geographic access to preferred cost-sharing pharmacies.

Consequently, CMS took action toward bridging the gap. They adopted a 3-pronged approach that included:

  • Working with outlier plans to address issues related to access and marketing
  • Building upon plans whose preferred cost-sharing networks are outliers in 2016
  • Publishing access levels for each plan that offers a preferred cost sharing benefit structure

Through the collective efforts of CMS and Part D sponsors, the access to preferred cost-sharing pharmacies has significantly improved.

“The bottom 10th percentile of plans in 2016 offer access within two miles to 71% of urban beneficiaries, as compared to 40% of beneficiaries in 2014,” according to Sean Cavanaugh, deputy administrator and director of the Center for Medicare at CMS.

Scope for Improvement

The National Community Pharmacists Association (NCPA), however, didn’t express extreme joy with the report. Speaking on behalf of NCPA members and beneficiary advocates, the association issued a statement that CMS still needs to do more work to achieve its aim of improving access to beneficiaries.

B. Douglas Hoey, CEO of NCPA, believes that CMS may have overshot its total numbers because it excluded from this analysis plans that were granted waivers to the retail pharmacy convenient access standard requirement. The marketing disclaimers have also been released well after the 2016 enrollment period concluded and 6 weeks into the plan year.

Additionally, Hoey believes that the importance of the data should be incorporated into Medicare Plan Finder prominently—and before beneficiaries research their enrollment decisions.

“Since beneficiaries need swifter relief and protection, we encourage Medicare officials to implement the ‘any willing pharmacy’ policy,” Hoey added.

Through the realization of the any willing pharmacy act, beneficiaries in medically underserved areas will be presented with more access to their prescription drugs at a community pharmacy that accepts the drug plan's terms and conditions and can serve those patients.

“This would be the best way to boost price competition and lowering of costs in the Part D program,” Hoey said.