Making Preferred Cost Sharing Pharmacies More Available

By: Sean Cavanaugh, Deputy Administrator and Director of the Center for Medicare, CMS

The benefits Medicare provides are only as good as the access beneficiaries have to them.  That’s why beneficiary access is a founding principle of our work at CMS.

Last year, we heard concerns that some beneficiaries did not have ready geographic access to preferred cost-sharing pharmacies.  Increasingly, Part D plans are creating smaller networks of pharmacies within their larger networks and offering lower cost-sharing arrangements to beneficiaries who use these preferred cost-sharing pharmacies. Plans market these lower cost-sharing arrangements, which are appealing to beneficiaries looking to save money on their prescription drugs.  However, in some instances, these pharmacies were not geographically accessible to the beneficiaries in the plan.

In our analysis of Part D beneficiary access to preferred cost-sharing pharmacies (https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/PCSP-Key-Results-Report-Final-v04302015.pdf), which was released in April 2015, we analyzed the availability of these pharmacies to Part D enrollees.  We were pleased to learn that most Part D enrollees live in areas where Part D plans provide reasonably robust preferred cost-sharing pharmacy networks. However, some beneficiaries in all areas, but particularly those in urban areas, face limited, or in some instances, no geographic access to preferred cost-sharing pharmacies.

We took action.  In last year’s (2016) Medicare Advantage Rate Notice and Part D Call Letter (https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2016.pdf), we announced that we would: 1) work with outlier plans to address our concerns about access and marketing; 2) require plans whose preferred cost-sharing networks are outliers (i.e., they offer significantly less access to preferred cost-sharing pharmacies) in 2016 to disclose in marketing materials that their plan offers less access; and 3) publish access levels for each plan offering a preferred cost sharing benefit structure.

Plans responded.  We are pleased to share that, based on data we are posting on cms.gov today (https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/index.html), access to preferred cost-sharing pharmacies has improved.  The bottom 10th percentile of plans in 2016 offer access within two miles to 71% of urban beneficiaries, as compared to 40% of beneficiaries in 2014.

This is just one example of ways CMS and Part D sponsors are working together to improve Medicare beneficiaries’ access to benefits.

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