Provider networks under both public and commercial plans come in three basic models, said Charles Cote, vice president, strategic communications, Pharmaceutical Care Management Association (PCMA). As a general rule, the more restricted the network, the lower the costs, Cote noted.
Open networks, the most common arrangement under fee-for-service programs, accept virtually any willing provider prepared to sign a contract for a specified payment level.
Preferred networks — or narrow networks — direct their business to a select subset of providers willing to reduce prices in return for higher volume. Plans typically allow beneficiaries to use any provider, but use incentives to encourage beneficiaries to choose preferred providers.
The Aetna CVS/pharmacy Prescription Drug Plan, for example, uses $2 copays for about 800 generics and $1 copays on generics for hypertension, hypercholesterolemia, and diabetes to entice beneficiaries into preferred CVS, Walmart, and Sam’s Club pharmacies. Plan members can use other, non-preferred pharmacies, but copays are higher.
“The narrower preferred network offers an opportunity for a deeper discount to provide more value for members,” said Terri Swanson, vice president and head of Medicare Part D for Aetna. “We use benefit design to reinforce the use of preferred providers.”
The third model is a limited or closed network that requires beneficiaries to use specified providers. The best-known of these narrowest networks is Kaiser Permanente, which requires its 9 million members to use Kaiser providers, including pharmacies. There are exceptions for emergency care and other occasions when the patient may not be able to access a network provider, but out-of-network services generally are not covered.