Reimbursement win for retail pharmacies in CMS final rule

June 10, 2014

In May, the Centers for Medicare & Medicaid Services (CMS) issued its final rule for 2015 Part D prescription drug benefit programs, requiring increased price transparency for pharmacies by 2016.

Community pharmacies can finally breathe a sigh of relief when it comes to generic drug reimbursement. The Centers for Medicare & Medicaid Services (CMS) issued in May its final rule for 2015 Part D prescription drug benefit programs, requiring increased price transparency for pharmacies by 2016.

Within the final rule, Part D drug plans and pharmacy benefit managers (PBMs) are required to make available to contracted pharmacies the reimbursement rates for drugs under the maximum allowable cost (MAC) pricing standards. In addition, the MAC-based reimbursements-which are for generic drugs-will have to be updated ever seven days.

The National Community Pharmacists Association (NCPA) commended CMS for these provisions, which the association has been advocating for years, on behalf of community pharmacies. Currently, community pharmacies have been subjected to “take-it-or-leave-it contracts” with PBMs without reimbursement rate transparency for generic medicine.

“While we would prefer that this provision take effect prior to the 2016 plan year, we appreciate CMS finalizing this provision that will provide pharmacists with critical information about how they will be reimbursed for generic drugs,” said NCPA in a statement.

“CMS heard the concerns of many community pharmacies and rejected the misleading arguments made by those opposing this portion of the rule. NCPA has worked for years to alert Medicare, Congress, and state legislators about these problems. Twelve states have enacted MAC laws to date,” NCPA noted.

CMS, however, did not move forward with the pharmacy choice provision that would have allowed independent pharmacies the ability to compete with preferred pharmacy networks. NCPA asked CMS “to continue to closely scrutinize these arrangements, including whether they may be discriminatory against certain beneficiaries.”

 

Medicaid AMP-based FULs

In other news, CMS plans to publish the final Medicaid average manufacturer price (AMP)-based federal upper limits (FULs) in July, and expects them to take effect immediately.

The National Association of Chain Drug Stores (NACDS) expressed its concern about the problems associated with immediate implementation. The association noted that Medicaid beneficiaries may be adversely affected with patient access issues to pharmacy care. NACDS supports a one-year transition period for states to implement the FULs.

Nine senators have written a letter to HHS Secretary Kathleen Sebelius about the challenges faced by states if the Medicaid FULs go into effect this year.

“We believe that such a rapid implementation will pose problems for under-reimbursement of Medicaid prescriptions at the state level, which may pose problems for beneficiaries,” the senators wrote. “We encourage CMS to establish a one-year transition period for state implementation of the FULs as well as for implementing any necessary dispensing fee changes by the states once the new FULs have been published.”

NACDS President and CEO Steven C. Anderson, IOM, said, “We appreciate the leadership of Senators Mark Warner (D-VA), Johnny Isakson (R-GA), and the support of their colleagues in recognizing how this immediate reimbursement change could impact access to pharmacy services for low-income Americans.”