MAPD Contracting Questions

Are there provider limitations?
HMOs generally have very restrictive networks where patients may only utilize providers in the plan networks. These networks can be extremely competitive for community pharmacies to enter. PPOs allow beneficiaries to obtain care outside the network if they pay higher amounts. PFFS currently operate under “any willing provider” contracts. However, you must be willing to accept the plan's terms and conditions, which are usually available on the plan’s Web site. As a comparison, PDPs also have “any willing provider” requirements.
Does the plan utilize and/or encourage mail order (prescriptions and HME, including diabetes supplies)?
Mail order programs are a part of many MA plans. As part of the “level playing field” provision of Part D, plans cannot mandate mail order but they can provide incentives for beneficiaries to use mail order rather than going to their local pharmacy for prescription drug benefits and HME supplies such as diabetes supplies.
Does the MAPD plan offer pharmacy-delivered MTM services or other pharmacy-based clinical interventions for its patients?
As part of the Medicare Modernization Act, all Part D and MAPD plans are required to have an MTM program for targeted high-risk beneficiaries. These plans are given flexibility to establish parameters for targeting these beneficiaries and how they administer the program. MAPDs are more likely than PDPs to have strong MTM and clinical programs because, while the MTM program may increase an MAPD plan’s prescription drug spending, the benefits on decreased hospitalizations and physician visits make up for this risk.
Does the MAPD plan offer adequate pharmacy reimbursement/dispensing fees?
Congress intended for pharmacy reimbursement and price concessions to be negotiated. While 44% of all independent pharmacies accept all Part D contracts, the majority of independents are choosy about the contracts they accept. It is important to remember your costs of dispensing before accepting contracts. A recent Grant Thornton study found that the average pharmacy cost to dispense is $10.50 in chain and independent pharmacies. This figure is just an estimate and varied widely based on location. It is important that you know how to calculate your pharmacy's cost to dispense. A quick and easy method is to take all your costs, including overhead and staffing, for the past year and divide it by the total prescriptions in that year. There are other methods of calculation which you can find on NCPA's Web site at www.ncpanet.org.
How does the plan manage its agent force?
Due to the complexity of Medicare Advantage products, all Medicare Advantage enrolments must be taken by licensed insurance agents. Some Medicare Advantage plans recently have come under fire in the media for misleading, aggressive sales practices. Obviously if you have these agents in your pharmacy, it can reflect poorly on your business. However, recent legislation passed in July 2008 and new rules issued in September limit these agents’ activities and add greater oversight of plans’ marketing activities.