R.Ph.s told they can help shape nation's direction

June 19, 2006

Pharmacy may be at a moment of unaccustomed visibility just at a time when the nation's direction is in flux, political commentators told the several hundred pharmacists who went to lobby Washington during the National Community Pharmacists Association's legislative conference last month.

Chuck Todd, National Journal's Hotline editor and political analyst for major TV and newspaper outlets, believes that Medicare Part D implementation has been a "third test," after the war in Iraq and Hurricane Katrina, when government was seen as not handling things well. Whether Part D becomes a plus or a minus for the Republicans will depend in large part on whether the "donut hole" in the benefit, due to hit many beneficiaries soon, sparks voter anger just weeks before elections.

Craig Crawford, contributing editor for Congressional Quarterly, said Medicare beneficiaries' perceptions about Part D are critical, because "older people show up and vote." He urged pharmacists to be sure their local media and politicians hear their perspective.

Pharmacists also applauded his statement that by July, the recently announced standard electronic response codes will be required procedures for drug plans, not just designated best practices. Those messages, meant to help pharmacists avoid calling the plans, include rejection explanations, prior authorization requirements, daily dose limitations, quantity limits, and age and gender contraindications. And starting with the next plan year, CMS will prohibit the practice of "co-branding" drug cards with the logos of specific drugstores. CMS has investigated every payment issue presented, McClellan said. "If you feel that a plan fails to meet the terms of your contract, bring it to us."

CMS asked plans to extend the transitional supply of off-formulary medications from 30 to 90 days, McClellan said, and to continue coverage for the year if a patient was stabilized on a covered medication when he/she enrolled-even if that plan took the drug off its formulary. CMS also told plans to expand their window for pharmacies' claims submissions from the typical 30-90 days to 180 days during this initial phase.

Knowing R.Ph.s had dispensed many Rxs without adequate billing information, McClellan said, "We want to make sure pharmacists get paid for these costs for all beneficiaries with Medicare coverage." Progress, he said, is seen in the decline in inquiries to the "E1" system, which helps pharmacists determine eligibility for individuals with no proof of enrollment. They have dropped from almost 1.5 million on Jan. 4 to about 120,000 a day in early May.

Since he moved to CMS two years ago, McClellan said, "We have put pharmacists on our staff in our central office and in every one of our regional offices around the country." Pharmacists are now "an essential and integral part of our agency just as prescription drugs are an absolutely essential part of modern medicine," he said.

With pharmacists worried that plans will soon begin to look back at some of the relatively flexible approvals from the first months of Part D, find cases where the drugs involved were not covered, and demand money back from them, McClellan said CMS would work directly with R.Ph.s in those cases.

Despite these assurances from McClellan, NCPA meeting attendees met with their Congressional representatives and staff to lobby on several payment-related issues: to require that clean, electronic claims be paid by the plans within 14 days, with electronic deposit; that AMP not be used as the baseline for reimbursement for generic drugs in Medicaid; that independent pharmacists be given the right to collectively negotiate with healthcare plans and insurers; and that there be more scrutiny of pharmacy benefit managers.