NCPA to Medicare: Rein in Egregious Pharmacy Audits; Reform Preferred Networks; and Curb Mail Order Waste in 2014 Prescription Drug Plans



Alexandria, Va. March 1, 2013 - As officials with the U.S. Centers for Medicare and Medicaid Services (CMS) determine requirements for Part D prescription drug plans (PDPs) in 2014, the National Community Pharmacists Association (NCPA) submitted written comments urging them to take action on a wide range of anti-patient, anti-pharmacist practices about which CMS recently expressed concern.

In a Feb. 15 draft "call letter," CMS outlined proposed policies for drug plans next year and invited comments on those proposals. The letter touched on several issues previously raised by NCPA staff and member pharmacists, including egregious pharmacy audits, exclusionary "preferred pharmacy" plans and wasteful auto-shipping by mail order pharmacies that inconveniences patients and raises costs. NCPA's comments ask the agency to include in its final 2014 policy requirements that plans address these issues.

"Every day independent community pharmacists help seniors improve their health through the appropriate and safe use of prescription drugs. Local pharmacists also help Medicare keep costs down by preventing the need for costlier medical interventions and promoting the proper use of generic drugs. However, their work is undermined by practices such as abusive pharmacy audits and discriminatory plan designs," said NCPA CEO B. Douglas Hoey, RPh, MBA. "NCPA and its members have notified CMS of these harmful practices repeatedly. We appreciate the recent acknowledgement by Medicare officials of these problems and we urge them to take decisive action to address them for 2014, if not sooner."

NCPA's comments touched on the following issues, among others:

  • Rein in egregious pharmacy audits. Community pharmacists support legitimate auditing practices to uncover true fraud waste and abuse, but it is wrong for PDP pharmacy benefit managers (PBMs) to hire auditors to find the slightest of pharmacy clerical errors so they can recoup the monies paid for a legitimate prescription claim and then turn around and not accurately report such gains to Medicare. CMS should make clear in the final call letter that recoupments can only occur when true fraud has occurred; introduce a consistent auditing standard across Part D plans; and force plans to pay back pharmacies for every claim that was recouped on a technical error.
  • Reform the practices of preferred pharmacy network plans. NCPA remains concerned about preferred pharmacy networks and, like CMS, questions whether drug costs in such PDPs are in fact lower compared to costs in PDPs without preferred networks. NCPA asks CMS to further investigate these issues and to ban "pay-to-play" arrangements whereby pharmacies must pay $1.00 (or more) per claim to participate among a plan's "preferred" pharmacies.
  • Protect beneficiaries from deceptive mail order pharmacy tactics. Medicare officials have repeatedly criticized inappropriate steering of patients against their will to mail order pharmacies under the guise of "prior authorization" requirements, yet the practice continues. NCPA strongly encourages CMS to take further action and to stop these egregious practices once and for all, such as through adoption of a universal model prescription transfer letter.
  • Preserve beneficiary access to compounded medications. CMS should omit from the final call letter any prior authorization requirements for compounded medications. Such a mandate would represent a significant federal infringement onto medical practice and doctors' prescription rights, and would decrease and delay beneficiaries' access to care.
  • More utilization of medication therapy management (MTM). CMS is right to promote on the Plan Finder website and in the "Medicare & You" handbook, the importance of MTM. Greater use of pharmacists providing MTM and refill synchronization (such as Simplify My Meds™) can lead to better health outcomes at lower cost.
  • Reduce wasteful spending generated by mail order pharmacies' auto-shipping. CMS should establish clear policies and parameters surrounding auto-ship refill programs. While requiring patient consent prior to the delivery of each refill or new prescription is a good start, beware of mail order facilities trying to undermine this requirement through blanket consent agreements.

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