How wide is narrow?
Creating a narrow network is as much art as science. Payers must balance the financial savings that stem from restricted provider networks with beneficiaries’ need for pharmacy access.
There are more than 60,000 pharmacies in the United States. That is more than the total number of franchises in the top eight fast-food chains combined, according to PCMA. There are also geographic areas, generally in rural regions, with just one pharmacy or none within a reasonable distance of where patients live and work.
Patient-access rules also play a role. Medicare Part D pharmacy access is governed by rules set by the Centers for Medicare and Medicaid Services (CMS).
According to the National Community Pharmacists Association (NCPA), in an urban area, at least 90% of Medicare beneficiaries in the Part D service area, on average, must live within two miles of an in-network retail pharmacy.
In suburban areas, at least 90% of beneficiaries must live within five miles of an in-network retail pharmacy.
And, in rural areas, at least 70% of Medicare beneficiaries in the Part D service area, on average, must live within 15 miles of an in-network retail pharmacy.
However, these standards apply only to the plan’s primary pharmacy network. Plans are not required to meet the same standards when establishing preferred pharmacy networks, according to NCPA. And CMS does not currently apply the “Any Willing Provider” provision to pharmacy networks.
Medicaid pharmacy programs are governed by other rules, including state requirements. Commercial plan access is largely dictated by the plan sponsor.