A: The Medicare Modernization Act, or MMA, was passed on December 8, 2003. Most notably, it established a voluntary drug benefit for Medicare beneficiaries, known as Medicare Part D. Medicare Part D prescription drug insurance coverage began January 1, 2006, for those who are eligible under Medicare. The coverage is not available directly from Medicare but is provided through private health insurance companies that have contracted with Medicare to provide this coverage to beneficiaries.

A: The Centers for Medicare and Medicaid Services (CMS) has identified two categories of entities to facilitate the prescription drug program to Medicare beneficiaries: Prescription Drug Plans (PDPs) and Medicare Advantage Prescription Drug Plans (MAPDs). PDPs must offer a basic prescription drug benefit. PDPs will be administered by PBMs and other interested parties. In conjunction with a managed care plan, MAPDs must offer either a basic benefit or broader coverage for no additional cost. Medicare Advantage plans were formerly known as Medicare + Choice plans.

A: No, plans cannot require enrollees to use a mail order pharmacy. However, they can offer mail order service to their patients.

Q: Can my pharmacy be shut out of Part D plans? 

A: Possibly—the MMA contains a provision that any pharmacy that wishes to participate in a Medicare plan can participate if they accept the standard terms and conditions of the participating pharmacy agreement. However, plan sponsors can develop "preferred networks" that are not open to all providers.

A: The Medicare Modernization Act included a provision that plan sponsors could tier their network to include "preferred pharmacies." Part D plans can establish "preferred pharmacies" which can provide more advantageous copays and co-insurances to beneficiaries in exchange for lower reimbursement to participating pharmacies. Plans must disclose to their members that other pharmacies, besides their preferred pharmacies, are also available.

A: CMS will not dictate what plan sponsors should be offering pharmacies in terms of reimbursements and dispensing fees.

However in section §423.100 of the final rule, CMS determined that the dispensing fee will include only those activities related to the transfer of possession of the covered Part D drug from the pharmacy to the beneficiary, including charges associated with mixing drugs, delivery, and overhead. The dispensing fee will not include any activities beyond the point of sale (that is, pharmacy follow-up phone calls) or any activities for entities other than the pharmacy. Therefore, activities related to drug utilization review (DUR) and medication therapy management (MTM), if covered by a plan, would not be included in the dispensing fee but rather billed separately.

Q: Can any pharmacy provide 90-day supplies at retail? 

A: Yes, if the participating plan offers a 90-day supply at mail. Section § 423.120(a)(10) of the MMA requires that a Part D sponsor must permit its Part D plan enrollees to receive benefits, which may include a 90-day supply of covered Part D drugs, at any of its network pharmacies that are retail pharmacies. However, a Part D plan may require a beneficiary to pay any additional cost sharing incurred as a result of receiving a 90-day supply at retail.

If the plan sponsor does not offer a 90-day supply via mail order, the plan is not required to offer a 90-day supply option at retail.

A: Under section 1860D-4(k)(1) of the MMA, Part D sponsors will be required to ensure that pharmacies inform enrollees of any price differential between the brand name price and the lowest-priced generic version of a covered Part D drug available at that pharmacy. It is the plan’s responsibility to verify that community pharmacies are complying with this requirement. Bottom line: When you fill a Medicare prescription that has a generic equivalent, you must indicate the price differential between the price of that brand name drug and the price of the lowest-priced generic version of that drug available at your pharmacy.

A: Yes, all plan sponsors must contract with any willing LTC provider to provide prescription drugs to Medicare beneficiaries residing in LTC facilities. Plan sponsors will be required to network with LTC pharmacies separately from regular network contracting.

CMS will be assuring that residents of LTC facilities have pharmacy service that meets their specialized needs including:

CMS will require plans to demonstrate that they have contracts with a sufficient number of LTC pharmacies to ensure "convenient access" to prescription drugs for institutionalized beneficiaries within the service area. CMS expects that each LTC facility will select one or more eligible network pharmacies to provide a plan's long term care drug benefits to its residents.

Similar access and contracting provisions exist for home infusion and Indian Tribes, Tribal organizations, and urban Indian organization (I/T/U) pharmacies as well.

A: TrOOP (true out-of-pocket) costs will determine the start of the catastrophic coverage. Most third-party assistance, such as that from employers and unions, does not count toward the TrOOP threshold. However, contributions from State Pharmaceutical Assistance Program (SPAPs) will count toward TrOOP.

It is the responsibility of the PDP to monitor TrOOP. On the retail level, there are two ways for pharmacists to monitor TrOOP on behalf of their patients: (1) through a "TrOOP facilitator" or (2) by calling 1-800-MEDICARE.

CMS has contracted a TrOOP facilitator to monitor true out-of-pocket costs for Medicare beneficiaries. On the pharmacy level, pharmacists will need to monitor coordination of benefits (COB) for these beneficiaries to know (1) who to bill and (2) in what order to bill for these claims. One of the roles of the TrOOP facilitator is to provide pharmacists with the information needed to properly bill claims (cardholder ID number, group number, BIN, PCN, etc.) Pharmacists will incur an additional switch fee to receive this information.

A: There are three ways for pharmacists to determine eligibility and correct billing information: (1) through the TrOOP facilitator, (2) by utilizing the point-of-sale facilitated enrollment process, or (3) by calling 1-800-MEDICARE.  

A: Individual prescription drug plans will determine fees associated with medication therapy management programs, which "may (emphasis added) include pharmacists or other providers". Plans will have the flexibility to establish their own fees, although these fees must take into account the time and resources associated with implementing the medication therapy management program. CMS will require potential PDP sponsors to explain, as part of their applications, how their fees account for the time and resources associated with their medication therapy management program. MAPD plans are exempt from this provision.

A: Section §423.153(d) states that a Part D sponsor must have established a MTM program that:

 

CMS envisions that plans will use system edits—computerized notices that appear on the pharmacists' computer when a beneficiary fills a prescription—as the most common method for identifying targeted beneficiaries to individuals responsible for providing the services (e.g. pharmacists). CMS expects that plans and pharmacists will coordinate these edits as part of the terms and conditions of their contracts.

A: Yes, mail order operations will be able to provide MTM services. CMS envisions that MTM encompasses different types and levels of service, some of which are appropriate for mail order operations.