The new Medicare law requires that plan sponsors allow patients to receive a 90-day supply at retail if that option is available through a mail order pharmacy. Retail pharmacies will be given the opportunity to fill a 90-day supply of drugs under the same terms and conditions as the mail order pharmacy.
This was an attempt by Congress to “level the playing field” between retail and mail order pharmacies. The rationale was that all things being economically equal, the beneficiary will make a choice between the retail pharmacy and the mail order pharmacy based upon the quality of service and convenience.
With some prescription drug plans (PDPs) submitting retail extended supply contract reimbursement rates at all time lows (for a contract comparison through NCPA’s Contract Clearinghouse, visit http://www.ncpanet.org/cgi-bin/www_protect.cgi?file=ncpas_contract_clearinghouse/index.shtml), some community pharmacies are not financially able to accept these terms. Often these contracts represent below cost reimbursement rates. This likely violates “below cost” state laws in 22 states – in these states it is illegal to sell routinely below cost. Consequently, some community pharmacies cannot provide a 90-day supply to Medicare beneficiaries starting January 1.
The Centers for Medicare & Medicaid Services will require that a PDP contract with “some” retail pharmacies to ensure “adequate” patient access to a 90-day supply at retail when mail order is utilized for extended day supply. It is important to note that even if you accept the terms and conditions of the extended day supply contracts, the patient will be charged any price differential from mail order’s cost sharing. With price differentials and limited access requirements for 90-day supply networks, how level is the level playing field requirement?
Fortunately, Medicare Part D is a whole new ballgame. You have a choice to
reject unfair agreements. The Medicare enrollment process empowers you to
keep your customer base without accepting unfair contracts. It is more important
than ever that community pharmacists work with Part D plan sponsors that work
with them.