How Will CMS Changes to Medicare Part D Affect Retail Pharmacy in 2018?


See what changes are coming to retail pharmacy for Medicare Part D in 2018.

The Centers for Medicare and Medicaid Services recently released “Advance Notice of Methodological Changes for Calendar Year 2018 for Medicare Advantage Capitation Rates, Part C and Part D Payment Policies and 2018 Call Letter,” a riveting 159 pages of information.

In case you don’t have time to read the entire document, we will touch on a few highlights for you, particularly those that will have a direct impact on our retail pharmacy friends. We won’t really touch on reimbursement changes, as they are very detailed and not something that would be on the radar of the average retail pharmacist. Our main focus will be changes to star ratings and MTM changes.

Benefit Changes

Your customers will be very concerned about out-of-pocket expenses such as deductibles and co-pays. The bad news is that these expenses will be increasing. The good news is that the increases will be small. Deductibles, coverage limits, and out-of-pocket thresholds will be increasing by less than 2% as compared to 2017.

Donut Hole

The “donut hole” has been frustrating seniors for years. From dramatically increasing monthly costs, to causing doctors to forego more effective medications because of cost, this provision of Medicare Part D has been nothing more than a burden on patients. Currently patients can expect to pay 40% for brand name drugs and 51% for generics. Those numbers will decrease to 35% and 44% respectively in 2018. By 2020 the donut hole will, thankfully, exist no more.

MTM Changes

Many retail pharmacists spend portions of their time chasing dollars for their stores by performing MTM’s. Insurance companies will identify patients who need some encouragement to improve their medication adherence, or similar star rating measures. The insurance company will rely on the people who are closest to these patients - their pharmacists - to provide this encouragement. As a reward, they will pay the pharmacies a few dollars for each successful intervention.

Most of the existing star rating measures will remain in place. Medication adherence will continue to be measured for diabetes medications, statins, and certain blood pressure medications. Pharmacies will be able to earn money by encouraging on-time refills, changing to a 90 days supply, and making adherence check-in phone calls to patients.

CMR’s (Complete Medication Review) will still be a focus from insurance plans (and from your boss). This is the most lucrative MTM opportunity for good reason. It takes a lot of time and work to complete.

Display Measures

One of the biggest changes for retail pharmacists is that “high-risk” medications will not be measured for star ratings, but will instead be “display measures.” This will be great news if your company is tracking your success rate in completing MTM’s. The most prominent example of this is the use of zolpidem in the elderly. There are significant reasons why zolpidem has been labeled high risk, and we agree that its use should be discouraged, or at least be limited in the elderly. However, this can be a very hard sell to patients who can’t sleep, or perceive that they won’t be able to sleep without this medication. Their hesitation, or refusal, to change can bring down your overall success rate rapidly.

Overall, theses changes will not dramatically alter what we do every day, but it is good to get a peek at what will be coming in the future.


Advance Notice of Methodological Changes for Calendar Year 2018 for Medicare Advantage Capitation Rates, Part C and Part D Payment Policies and 2018 Call Letter. CMS website. Published February 1, 2017. Accessed May 1, 2017.

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