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    CMS changes attitude toward Part D plan arrangements

    Preferred provider networks hammered; other changes imposed

    Ned Milenkovich, PharmD, JD. CMS changes attitude toward Part D plan arrangements. Drug Topics. March 2014.Ned Milenkovich[Editor's note: This article went to press before CMS decided not to move forward with the proposed rule.]

    The Centers for Medicare and Medicaid Services (CMS) has proposed new rules making significant changes to Medicare Part D, such as the “any willing pharmacy” contracting requirement, among other changes. The proposed rule was published in the Federal Register on January 10, 2014, and comments were due by March 7, 2014.

    Non-interference provision

    CMS is proposing a modified interpretation of the existing non-interference provisions. The new interpretation would remove any limitation on CMS’ regulation of the relationship between pharmacies and plan sponsors. As a result, CMS is able to propose several new requirements consistent with this new interpretation for relationships between plan sponsors and pharmacies.

     

    “Any willing pharmacy”

    CMS is proposing changes to its interpretation and application of two statutory provisions:

    • Ÿ The provision establishing the obligation of plan sponsors to contract with “any willing pharmacy”
    • Ÿ The provision giving plan sponsors the flexibility to create tiered pharmacy networks, with a lower cost incurred for drugs dispensed at certain network pharmacies.

    Previously, plan sponsors and “preferred” pharmacies could establish contracts containing a lower cost-sharing obligation for covered Part D drugs. CMS now intends to require plan sponsors using a tiered pharmacy design to develop two sets of contracting terms and conditions, “standard” and “preferred,” for every type of similarly situated pharmacy.

    In addition, pharmacies offering preferred cost-sharing must meet a negotiated price “ceiling,” which may not be more than the lowest negotiated price — the “floor price” — established by the plan sponsor. CMS also intends to cap the number of cost-sharing levels in plan benefit designs.

    Ned Milenkovich, PharmD, JD
    This article is not intended as legal advice and should not be used as such. When legal questions arise, pharmacists should consult with ...

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