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Topic: Part D
On May 11, 2018, President Trump unveiled his Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs entitled “American Patients First”. The President emphasized lowering drug prices as one of his greatest priorities during the campaign and promised to use the federal government’s purchasing power to negotiate lower drug prices to protect consumers, in particular Medicare beneficiaries, from being ripped off by greedy drug companies.
The Gorman Health Group 2018 Client Forum concluded last week in Las Vegas with over 300 of our closest clients and partners. As we enter our 22nd (!) year, we returned to the Red Rock Resort where a great time and shared learnings were had by all.
As we head into the Centers for Medicare & Medicaid Services (CMS) program audits, it’s important for Part D plan sponsors to review their tiering exception policies. Many plans get tripped up in Coverage Determinations, Appeals, and Grievances (CDAG) cases due to tiering exception findings. Chapter 18 of the Prescription Drug Benefit Manual, Section 30.2.1 – Tiering Exception, allows enrollees to obtain a non-preferred drug in a higher cost-sharing tier at the more favorable cost-sharing terms applicable to drugs in a lower cost-sharing tier. Non-formulary drugs are not eligible for a tiering exception.
The Wall Street Journal reported last night (Cigna Nears Deal to Buy Express Scripts) that Cigna is in final talks to acquire Pharmacy Benefit Manager (PBM) Express Scripts (ESRX) for a whopping $67 billion. ESRX was the last truly independent major PBM, and the deal signals the end of an era…and ushers in a new one, further blurring the lines between insurers, providers, and their primary vendor. The combined entity will reach over 250 million people and will have a ripple effect on many of their competitors.
In 2015, plans were met with the first “a-ha” moment when the Centers for Medicare & Medicaid Services (CMS) published the 2016 Star Ratings Medication Therapy Management (MTM) Comprehensive Medication Review (CMR) completion Star Ratings cut points indicating, at least when it came to delivering a completed CMR to a member, some plans were clearly outperforming others. Since then, the stakes have continued to be raised on MTM vendors or those conducting MTM in-house to meet the challenge of how to cost effectively improve their delivery of completed medication reviews. This is especially challenging given the varying nature of plan delivery types and the vastly different member demographics for whom they provide services.
On February 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released its 2019 Advance Rate Notice (Part II) and Draft Call Letter. CMS estimates an expected increase of 1.84% to payments in 2019. CMS says its estimates do not reflect underlying coding trend, which it expects to increase risk scores by 3.1% in 2019.
“There’s no harm in hoping for the best as long as you’re prepared for the worst.”—Stephen King