Medicare Part D Enrollment Tools

Start Educating Your Patients Early to Avoid Confusion, Disruption

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Medicare Part D open enrollment for 2019 is still more than two months away, but it's time to prepare for plan change season and the stress and confusion it brings.

As in past enrollment periods, some of your Part D patients are likely to receive confusing or incomplete information about which pharmacies they can use in a particular plan's Part D network. Some of these communications mislead patients into thinking that if your pharmacy is not preferred in a plan, they cannot fill prescriptions there.

Rather than scrambling to counter confusing and misleading communications that may come late in the enrollment period, start educating your patients now and offer to answer questions and assist in plan comparisons.

American Pharmacies has prepared a customizeable letter that you can send to select patients who need help with their plan choices or have questions about whether they should use a preferred or non-preferred network pharmacy. The letter is in Microsoft Word format and can be individualized with your own pharmacy logo, name and address/phone number. We also are providing a Part D bag clipper and a half-page flier that you can print to hand out to patients or use as a bag stuffer. Use the links at the top of this article to download.

Part D Resources
For You & Your Patients

Go to our Resources Page for a downloadable patient letter, bag stuffers & clippers, and links to helpful online tools.

Important Part D Changes for 2019

  • CMS has codified the current Part D Star Ratings system (with a few modifications) for the 2019 contract year. It also lengthened the process for modifying existing measures or adding new ones, making Star Ratings changes part of its annual Notice and Call Letter Process. See the 2019 Part D Star Ratings Measures Here.
  • CMS will allow Part D plans to begin making midyear formulary changes as well as quick substitutions for certain generic drugs.
    Plans will be able to remove brand drugs from their formulary or revise their preferred or cost-sharing status if they replace them with therapeutically equivalent new generics. Plans will no longer have to notify patients or CMS before making such changes.
  • After receiving complaints that some pharmacies with atypical business models were denied network participation by some Part D plans, CMS has clarified that the Any Willing Pharmacy Requirement applies to all types of pharmacies. While Part D plans may still define terms and conditions for different types of pharmacies, they cannot legally exclude any willing pharmacy from network participation simply because the pharmacy does not fit into its pharmacy classification system.
  • CMS has narrowed its definition of the term "marketing" in Part D to mean materials and activities intended to influence enrollees' plan choice decisions. Only materials meeting this definition will receive close CMS review, while the agency will relax its oversight of "communications" and "communication materials." You should be on the lookout during 2018 open enrollment for communications from Part D plan sponsors and PBMs that aren't overt marketing, but attempt to influence enrollees' plan choices through confusing statements about network pharmacies and co-payments.

The True Impact of Preferred Networks

In this time of restricted Part D networks and growing DIR fees, it does not make economic sense to participate as a preferred provider in every Part D plan. The negative margins that you would experience as a preferred provider in some Part D plans simply cannot be overcome through increased script volume.

AmerisourceBergen's Elevate Provider Network has proven that profitability is possible in Part D plans through careful plan analysis and by not seeking preferred provider status in plans that essentially guarantee negative margins. In understanding Elevate's decision to avoid preferred provider participation in certain Part D plans, you should remember:

  • LIS (low-income subsidy) patients pay the same co-pay regardless of whether or not you are a preferred provider. Full-benefit, dual-eligible LIS patients (those on Medicaid) will have a zero copay in any Part D plan. Other LIS patients will have the same fixed co-payments in all plans.
  • In some areas, LIS patients represent more than half of a plan's patient count. If you are a high Medicaid percentage pharmacy, the impact from not being a preferred network pharmacy will be greatly minimized.
  • Remember that patients who leave your pharmacy over a small co-pay differential are not likely to be your most profitable patients or the ones purchasing your front-end merchandise.

Cultivating Patient Loyalty

The fact that your pharmacy is not preferred with a given Part D plan does not mean your patients need to find another pharmacy or another plan. Patients choose their Part D plan based on many variables, only one of which is cost and convenience of the plan's network pharmacies. Patients typically look closely at:

  • Monthly premium;
  • Annual deductible;
  • Co-pays;
  • Coverage during the donut hole;
  • Formulary; and
  • The plan's pharmacy network.

Your patients come to your pharmacy for a reason... Identify the values they perceive in you and reinforce them every way you can. One of the best ways you can do that is by being a helpful and empathetic resource for their Part D decisions.