CMS Releases New Guidance for 'Any Willing Pharmacy' Policy

Medicare Part D contracting transparencies among issues that prompted action.

Medicare Part D contracting transparencies among issues that prompted action.

The Centers for Medicare and Medicaid Services (CMS) recently provided a guidance memorandum to Medicare drug plan sponsors regarding the “any willing pharmacy” (AWP) policy after significant disruption to patients and community pharmacists that occurred in early 2015.

Reports of these issues included concern over the transparency and timing of sponsors’ AWP contracting processes, as well as the content of their standard terms and conditions. CMS recently provided a detailed explanation of the Part D program’s AWP requirement.

Section 1960D-4(b)(1)(A) of the Social Security Act requires a Part D prescription drug plan to permit “the participation of any pharmacy that meets the terms and conditions under the plan.”

Part D sponsors must contract with any pharmacy that meets Part D sponsor standard terms and conditions. According to the memorandum, “AWP refers to the requirement that Part D sponsors permit the participation in their Part D plan networks of any pharmacy that is willing to accept the sponsor’s standard contracting terms and conditions.”

The standard terms and conditions must be relevant and reasonable, according to the CMS.

In order to comply with the AWP requirement, Part D sponsors must make standard terms and conditions available for all Part D plans offered. For the terms to be considered reasonable and relevant, they must identify for the pharmacy the plan that they apply. The offer must contain language that commits the Part D sponsor to include the pharmacy in the identified plan upon the pharmacy’s acceptance of the terms and conditions.

Sponsors may modify some of their terms and conditions in order to encourage participation by particular pharmacies; however, the terms and conditions must establish a “floor” of minimum requirements that all similarly situated pharmacies can abide by. These include conditions of participation related to health and safety or financial integrity.

In addition to these terms, CMS expects all Part D sponsors to have standard contracting terms and conditions readily available for requesting pharmacies no later than September 15 of each year for the immediately succeeding benefit year. By mid-September, sponsors will have signed a contract with CMS obligating them to delivering the Part D benefit through an accessible pharmacy network during the upcoming year.

In addition, they will have provided information about that network to CMS for posting on the Medicare Plan Finder web site.

According to the CMS, there is no justification for a delay in response to a pharmacy’s AWP request made after September 15, 2015, due to the fact that all sponsors should already have standard terms and conditions readily available.

“Medicare officials recently outlined for drug plan sponsors that by September 15, they should have standard contracting terms and conditions available for community pharmacies promptly upon request for the following plan year. Such a requirement was among the list of suggested reforms that NCPA proposed earlier this year,” said B. Douglas Hoey, RPh, MBA, CEO of the National Community Pharmacists Association. “Plans have to reply to inquiries from pharmacies within 2 days. In addition, the guidance indicates that plan sponsors must also make this information available to CMS upon request so the agency can actively monitor compliance with the AWP policy.”

The guidance comes in part to alleviate the likelihood of repeating the debacle of early 2015 that affected approximately 400,000 Medicare beneficiaries, many caregivers, and community pharmacists.

“We strongly support CMS’ new guidance to plans and the agency’s efforts to mitigate the problems seen earlier this year,” Hoey said.

With the new guidance set in place, it will be easier for sponsors and pharmacists to move forward and properly navigate the AWP policy. As September 15 approaches, so too does the chance for those involved with the AWP policy to prove the guidance has helped and avoid any mistakes as seen early in 2015.