Voice Support to CMS for Pro-Pharmacy Provisions in 2014 Draft Call Letter
SAMPLE LETTER, PLEASE INCLUDE PERSONAL EXAMPLES
Submit electronically to: AdvanceNotice2014@cms.hhs.gov
March 1st, 2013
Subject: 2014 Medicare Part C and Part D Draft Call Letter
To Whom it May Concern:
I am writing in response to the release by CMS of the Medicare Part D draft Call Letter for 2014. I
applaud CMS for addressing certain issues in the Call Letter that have concerned independent
community pharmacies and our patients for many years. As an independent community pharmacist, I
wish to voice my support for the following provisions that focus on eliminating abusive practices by Part
D pharmacy benefit managers (PBMs) that have disadvantaged patients and independent community
pharmacies. I respectfully ask that CMS include these provisions in the agency’s final Call Letter for
2014:
Preferred Pharmacy Networks: We support the fact that CMS addresses some of the improprieties
regarding so-called preferred Part D pharmacy networks. My pharmacy is not offered the chance to
participate in the vast majority of these networks, which negatively impacts many of my patients who
are forced to pay higher co-pays to continue to fill prescriptions at their pharmacy of choice. Plans
should be required to offer any pharmacy willing to accept a plan’s terms and conditions the chance to
participate in the preferred network per statute (42 U.S.C. § 1395w-104(b)(1)(A)). In addition, CMS hits
the nail on the head when it says that some of these networks require pharmacy “pay to play” in these
networks. Where do these reverse pharmacy payments to the plans go? To the beneficiary? To
Medicare? Or to the bottom line of the plans? Why should I have to pay a plan to serve my patients?
In addition, many of my patients are confused by these preferred pharmacy networks’ marketing
activities. Because of the marketing, patients may believe that they can use any pharmacy in a
“preferred” plan and get lower prescription copays. Patients may only learn that this is not the case when
they come to my pharmacy, and then have to drive long distances to a remote preferred pharmacy in the
network to get the lower copays.
The plans also deceive my low-income patients into thinking that they can only go to a preferred
pharmacy to obtain the lowest copays on their medications, which is not true. The Call Letter provides a
clear reminder to all sponsors that beneficiary communications concerning preferred networks must be clear
and unambiguous. Under no circumstances may sponsors inform LIS-entitled beneficiaries that they must fill
prescriptions at preferred network pharmacies in order to get LIS copays. This means that both written and
verbal communications between plan representatives and Medicare beneficiaries must be differentiated by
LIS status, and I fully support this requirement.
Finally, there is evidence from the Part D plan finder tool that these preferred networks are charging
beneficiaries higher prices (or the same price) for medications than they can obtain at non-preferred
pharmacies like mine. It is not clear to me why a pharmacy would be designated as preferred if they are
not lowering prescription prices for beneficiaries. In fact, if a my pharmacy is being paid less for the
medications than a preferred pharmacy, and the beneficiary is paying more in copays at my pharmacy,
how can it be that Medicare is actually saving money?
Pharmacy Audits: We commend CMS for acknowledging that it is wrong for Part D plan PBMs to hire
bounty hunting auditors to comb through pharmacy files to find the slightest of clerical errors so they can
recoup the monies paid for a legitimate prescription claim and then turn around and not accurately report
their gains to the Medicare program. These are the most egregious of abusive auditing practices, and we
applaud the fact that CMS has blown their cover.
Community pharmacists understand and support legitimate auditing practices that uncover true fraud, waste
and abuse. However, as CMS notes, plans are recouping total payments when “non-financial data on the
claims transaction…such as prescription origin codes or prescriber identifiers, are determined to be
erroneous. The increasing incidence of these adjustments for ‘routine clerical errors’ rather than
incorrect payment amounts (financial errors) may be related to the incentives in contingency
reimbursement arrangements with claim audit vendors.” These practices should stop, and we ask that
CMS make clear in the final Call Letter that recoupments can only occur when true fraud has occurred.
Automatic Prescription Refills by Mail Order: Waste is rampant in mail order delivery of
prescriptions. Many patients that are forced into mail order have come into my pharmacy with thousands
of dollars of medications from mail order outlets that they didn’t order and don’t need. CMS
acknowledged that it has received complaints from patients who are receiving unnecessary refills of
medications they no longer take. In such instances, mail order pharmacies do not take the medication
back and return it to stock, nor do they reverse the transaction and claim. This creates unnecessary waste
and, as CMS concluded, leads to additional costs for both the patient and the Part D benefit overall.
Prescription refills should only be mailed to patients on their request and not be automatically shipped so
that mail order outlets can enrich themselves.
Conclusion
The draft Call Letter takes significant steps toward addressing Part D PBM abuses that have been
plaguing beneficiaries and pharmacies. I commend CMS for recognizing them for 2014. I urge that the
final Call Letter retain these sections to protect the interests of beneficiaries, further promote pharmacy
competition, and most importantly provide true patient choice.
Sincerely,