Medicare Part D and the Independent Pharmacy

April 27, 2015 | Tim Gallagher

CMS, the Centers for Medicare and Medicaid Services, recently finalized its policy updates for Medicare health and Part D drug plans.

CMS states: “As the Medicare Advantage marketplace continues to grow, consumers are getting access to better care through more choice and competition. Seniors and people with disabilities, including the dual-eligible population, will continue to have an extensive choice of plans, affordable premiums, and better and more transparent information about provider networks and pharmacies.”

After the Aetna fiasco this year, CMS is taking a closer look at preferred networks and access to pharmacies. This should be good for independents. The final changes should drive important improvements to the accuracy and transparency of provider networks, and continue to promote improvements in quality of care for beneficiaries.

What does this mean for pharmacy?

Managing your Star Ratings is more important than ever! CMS continues to update the Star Ratings measures to drive improved quality for Medicare Advantage and Part D enrollees.

Medicare audits will not go away and will, in fact, probably become even more commonplace. To enhance program integrity and payment accuracy, stringent oversight will be applied to Medicare Advantage plans—as it has been to other Medicare program providers--to ferret out instances of improper payments. Hopefully, there will be more transparency in the plans’ MAC pricing policies for generics developed by their partners in crime, the PBMs.

Pharmacies with well-organized strategies can help patients choose the best plans for them (those in which their local pharmacies participate) by using tools such as iMedicare. By maintaining accurate provider directories and making them widely available, final policies promise to keep enrollees better informed, to help them better understand their choices, and to make timely decisions about their care and their coverage. In addition, CMS will ensure that Part D sponsors provide clear and accurate access to information on preferred cost-sharing pharmacies in their networks so that all beneficiaries have access to affordable coverage.

AuditMedicaidMedicare Star Ratings

Tim Gallagher

Tim is a pharmacist and president of Sterling Specialty Pharmacy. He has practiced pharmacy for more than 30 years—much of it with the family-owned regional chain of pharmacies, Astrup/Sterling Drug—and has experience in community pharmacy, LTC pharmacy, and Specialty pharmacy. He is a graduate of South Dakota State University College of Pharmacy. In his spare time, Tim enjoys reading and spending time outdoors with his wife and their alpacas, angora goats, chickens, and honeybees.