Medicare Rx plan pays R.Ph.s for advice

November 7, 2005

Pharmacists participating in the Community CareRx (CCRx) Medicare prescription drug plan will be paid not only for their clinical expertise but also for their financial advice that helps beneficiaries select the most economical medications that are right for them.

Pharmacists participating in the Community CareRx (CCRx) Medicare prescription drug plan will be paid not only for their clinical expertise but also for their financial advice that helps beneficiaries select the most economical medications that are right for them.

A number of pharmacy-friendly features make CCRx stand out from the other nine national Medicare prescription drug plans that were approved last month by the Centers for Medicare & Medicaid Services. To begin with, pharmacists will be paid on a fee-for-service basis for providing medication therapy management (MTM) services to beneficiaries with multiple medications for multiple conditions. And they will also be paid to help those beneficiaries save out-of-pocket expenses through cost-effective drug selection.

Pharmacists will be paid to manage risk to help keep Rx costs down for the beneficiary and the plan, said Charles Hallberg, president-CEO, MemberHealth, an Ohio pharmacy benefit manager. For example, CCRx will pay a double dispensing fee for moving a patient to a preferred brand drug and it will pay an extra dispensing fee for generic drugs.

Created originally as a Medicare-approved drug discount card program by the National Community Pharmacists Association, MemberHealth, and Consumer Sciences Corp., CCRx will offer Medicare beneficiaries a choice of three Rx plans. Monthly premiums will range from $26.25 to $45.23 with deductibles of either $100 or $250. The plan's formulary exceeds United States Pharmacopoeia guidelines, covering more than 146 therapeutic drug classes. It also lets beneficiaries fill 90-day scripts at their local pharmacy. CCRx is hiring as many as 10,000 independent agents to go into pharmacies to enroll Medicare beneficiaries in the plan at no cost to the store, Hallberg said.

Instead of using the typical PBM approach of one-size-fits-all, CCRx has tailored its reimbursement to the economic realities in the 34 Medicare regions, said Hallberg. He added that the reimbursement levels were determined with the consensus of the CCRx board of directors, which includes pharmacy members.

The MTM piece of the CCRx plan has been subcontracted to NCPA, which has set up a separate company, Community MTM. The delivery of pharmacist services is Web-based and protocol-driven, said Bruce Roberts, NCPA executive VP-CEO. Using information from a patient's prescription drug data, the protocols recognize therapeutic or economic issues and alert the pharmacist to a specific intervention that's needed.

"It tells the pharmacist to do specific things related to the patient," said Roberts. "Pharmacists are paid to deliver those services on a scale of intensity. It might be something as simple as a phone call or something as intense as a 30-minute face-to-face medication review. We've been working with pharmacists on the protocols for about six months."

Community MTM was created to serve qualified beneficiaries in the CCRx Medicare plan, but Roberts and Hallberg agree that the concept has the potential to become a model for pharmacist services and reimbursement.

"Our vision is to get pharmacists recognized and paid for the value they bring in making sure prescription drugs are used properly," said Roberts. "We've developed a full-blown systematized approach to achieving that vision. Obviously we start with Medicare Part D and the targeted population, but it's ultimately about providing these services to any plan sponsor."