Note to readers from APhA Executive Vice President and CEO Tom Menighan: I’m on vacation this week, but that doesn’t mean big things aren’t happening in pharmacy. This week, CMS released the Medicare Part D final rule with its decision on the proposed Part D MTM expansion. I’ve invited Jillanne Schulte, JD, APhA Director of Regulatory Affairs, to update you on the issue and its impact on our profession.

On Monday, May 19, CMS released the long-awaited Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs Final Rule. In the final rule, CMS finalized provisions related to improved payment accuracy (specifically, returning and reporting of overpayments), Maximum Allowable Cost (MAC) pricing (plans and PBMs must make reimbursement rates for MAC drugs available to pharmacies beginning Contract Year 2016), Medicare enrollment requirements for professionals who order or certify Part D drugs, and debarment of Medicare professionals engaged in abusive prescribing patterns or practices. However, despite strong advocacy from APhA members and staff, CMS opted not to finalize the medication therapy management (MTM) expansion or the mail-service (CMS refers to this as “mail-order”) preferred cost-sharing changes at this time. But it is evident that pharmacists’ voices were heard loud and clear. CMS thanked stakeholders for “the strong support received” for both the MTM and mail-service cost-sharing provisions and stated that in both instances, the agency “will engage in new notice and comment rulemaking on [the issues] as warranted in the future.” 

Importantly, CMS’s comments clearly indicate that CMS continues to believe that Part D reforms are necessary. Regarding mail-service cost-sharing changes, CMS wrote, “We agree with many of the commenters who wrote that beneficiaries should be able to choose where they obtain their pharmacy services, and we are very concerned to hear that the current incentives (and potentially current marketing of pharmacies offering preferred cost sharing) lead many beneficiaries to believe that only those pharmacies offering preferred cost sharing can be used.” Similarly, regarding MTM services, CMS reiterated their value to patients and the overall health care system, noting that “MTM has been shown to improve drug therapy outcomes and lower costs, and we agree that the use of community-based resources for providing MTM services shows promise in improving access and quality.” CMS went on to note that “we still have concerns that many sponsors are applying restrictive criteria to narrow the pool of targeted beneficiaries for MTM rather than optimizing the eligibility criteria to offer MTM to beneficiaries who will most benefit from these services. These programs are not living up to our expectations.” In fact, CMS plans to increase scrutiny of plan MTM programs and is considering requiring plans to make data regarding MTM eligibility rates publicly available.

While we didn’t get the changes we wanted in this round, policy makers listened, and your hard work will likely keep the possibility of reform alive. And while CMS is moving slowly on these issues, Congress has shown a willingness to engage on MTM and preferred pharmacy network changes. APhA will continue to work closely with CMS, Congress, and other stakeholders to institute these much-needed reforms. Finally, a huge thanks to so many of you who sent personal comments to CMS and contacted your legislators in support of the MTM expansion and mail-service cost-sharing—your voices were heard. As we move forward on these issues, we will need you to once again speak on behalf of your patients and our profession.