More Medicare Part D Patients Can Access Preferred Cost-Sharing Pharmacies

New data from the US Centers for Medicare and Medicaid Services (CMS) show an improvement in the number of Medicare Part D beneficiaries who have access to preferred cost-sharing pharmacies.

In a recent CMS blog post, Sean Cavanaugh, deputy administrator and director of the Center for Medicare, explained how Part D plans are increasingly “creating smaller networks of pharmacies within their larger networks and offering lower cost-sharing arrangements to beneficiaries who use these preferred cost-sharing pharmacies.”

Although most Part D enrollees live in areas where their plans provide reasonably robust networks of preferred cost-sharing pharmacies, some beneficiaries—particularly those in urban areas—have either limited or no geographic access to such pharmacies, leading fewer patients to take advantage of lower out-of-pocket prescription drug costs.

“The benefits Medicare provides are only as good as the access beneficiaries have to them,” Cavanaugh pointed out. “That’s why beneficiary access is a founding principle of our work at CMS.”

To improve Part D patients’ access to preferred cost-sharing pharmacies, CMS has published access levels for each plan offering a preferred cost-sharing benefit and required outlier plans defined as those offering significantly less access to preferred cost-sharing pharmacies to disclose in marketing materials that their plan offers less access.

The definition of “access” varies by geographic location. In urban areas, access means having a preferred cost-sharing pharmacy within 2 miles of beneficiaries’ residences. In suburban and rural areas, the mileage limit is 5 miles and 15 miles, respectively.

According to CMS, the bottom 10^th percentile of Part D plans now offer access to 71% of urban beneficiaries, compared with just 40% of beneficiaries in 2014. Additionally, access levels for the bottom 10^th percentile of plans in suburban areas has increased to 95% in 2016 from 87% or lower in 2014, while access levels for the bottom 10^th percentile of plans in rural areas has increased to 82% in 2016 from 77% or lower in 2014.

Commenting on these data, National Community Pharmacists Association CEO B. Douglas Hoey, RPh, MBA, stated, “The CMS analysis documents progress, yet still identifies many plans that are ‘access outliers’ that impact a significant number of beneficiaries. Indeed, this total could be higher because CMS excluded from this analysis plans granted waivers to the retail pharmacy convenient access standard requirement.”

He also pointed out “the marketing disclaimers, while appreciated, come well after the 2016 enrollment period concluded and 6 weeks into the plan year.”

Nevertheless, the CMS data may support renewed efforts for HR 793, referred to as “any willing pharmacy” legislation, which was introduced in 2015. This federal bill would allow seniors in medically underserved areas to access lower co-pays at any pharmacy willing to accept a Part D drug plan’s “preferred pharmacy” terms and conditions.

US Representative Earl “Buddy” Carter, the only pharmacist in Congress, recently told Pharmacy Times that HR 793 is one of 3 major bills to which he devotes much of his energy on Capitol Hill.