The Med Diva

An insider's guide to Medicare Part D and more

Archive for the category “Restricted Network Plans”

Read the Fine Print Before Getting Locked Into a Restricted Network Part D Plan

Don't get locked into a Part D plan with a restricted pharmacy network unless it's right for you.

Don’t get locked into a Part D plan with a restricted pharmacy network unless it’s right for you.

As I’ve mentioned several times before, Medicare beneficiaries should always read the fine print and watch out for the terms “preferred network” or “restricted network” when choosing a Part D prescription drug plan (PDP).

Restricted network pharmacy plans encourage members to use national pharmacy chains (such as CVS or Walgreens), which are called preferred network pharmacies. These preferred pharmacies offer covered drugs to plan members at lower out-of-pocket costs than what the member would pay at a non-preferred network pharmacy. A non-preferred network pharmacy, on the other hand, is often the small community pharmacy in your town.

Many of the largest Part D plans have restricted networks, including Humana Walmart-Preferred Rx Plan, Aetna CVS/pharmacy PDP, First Health Value Plus PDP, Rite Aid EnvisionRx Plus, AARP Medicare Rx Preferred, and CVS Caremark Plus. Beneficiaries are attracted to these plans because of the low premiums and copays.

In its 2014 Call Letter, the Centers for Medicare & Medicaid Services (CMS) remind plan sponsors that beneficiary communications regarding preferred networks must be “clear and unambiguous.” In addition, CMS reminds Part D plans that the plans can never–under no circumstances–require beneficiaries who get Extra Help from Medicare and qualify for low-income status (LIS) to use a preferred network pharmacy in order to get their LIS copays.

According to groups like the National Community Pharmacists Association and the Indo-American Pharmaceutical Society, many Medicare beneficiaries are confused by Part D marketing activities that led them to sign up for a “preferred network” plan, only to later find out that the closest pharmacy in the preferred network is 20 miles from their home.

This week, the IAPS posted a sample letter to CMS on its website, and asked that every independent pharmacy owner cut and paste the letter and send it to CMS. Here is a portion of that letter:

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 (PBM’s) 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 co-pays. 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 co-pays.

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 co-pays at my pharmacy, how can it be that Medicare is actually saving money?


Pharmacist groups says CMS, “restricted network” Medicare Part D plans, deceived seniors

The local community pharamcy is often a "non-preferred" phamarcy in Medicare Part D plans.



As if Medicare Part D wasn’t confusing enough, beneficiaries now have to make sure they watch out for the terms “preferred network” or “restricted network” when choosing a prescription drug plan (PDP).

According to the National Community Pharmacists Association (NCPA), restricted network pharmacy plans are centered on national pharmacy chains (such as CVS or Walgreens) called “preferred network pharmacies.”  These preferred pharmacies offer covered drugs to plan members at lower out-of-pocket costs than what the member would pay at a non-preferred network pharmacy. (A non-preferred network pharmacy is often the small community pharmacy in your town.)

There are several national restricted network Part D plans, including Humana Walmart-Preferred Rx Plan, Aetna CVS/pharmacy PDP, First Health Value Plus PDP, Rite Aid EnvisionRx Plus, AARP Medicare Rx Preferred, and CVS Caremark Plus.

Last week, the NCPA asked the Centers for Medicare and Medicaid Services (CMS) to create a special enrollment period that would allow members of these plans to enroll in a new Medicare Part D prescription drug plan. The group says this action is needed for patients who believe that “material misrepresentations” led them to sign up for a “preferred network” plan with inadequate pharmacy access.

According to the NCPA, many people have claimed that they relied on CMS’ Medicare Plan Finder, as well as online advertising and/or enrollment agents, to help them find the best plan. They chose a plan based on the low, advertised co-pays, only to find out later the advertised co-pays were only for “preferred network pharmacies.” Now these members may have to travel 20 miles or more to a large chain pharmacy to get that advertised price.

Back in November, NCPA sent a letter to CMS urging the agency to modify the Medicare Plan Finder tool so it is perfectly clear that the lower co-pays are only available at a preferred pharmacy. They also asked CMS to require restricted network plans to clearly state in all communications that members must use a preferred pharmacy to get the lower advertised drug costs.

In a January 19, 2012, press release, NCPA Chief Executive Officer Doug Hoey, RPh, stated, “Every day about 10,000 Americans turn 65 and are eligible to enroll in a Medicare drug plan. Medicare should allow seniors who feel that they’ve been duped the same choice as those just entering the program. In addition, CMS should implement preventative steps to avoid a repeat of this situation next year.”

NCPA is asking community pharmacists to assist their patients in filling out a CMS complaint form, calling 1-800-MEDICARE, or filing a complaint via NCPA’s website if patients feel they were mislead and are experiencing pharmacy access issues.

Always Read the Fine Print When Comparing Medicare Part D Plans

On Tuesday, drugstore operator Rite Aid Corp. joined the prescription drug plan bandwagon by introducing a new Part D plan through a partnership with Envision Insurance. This announcement follows closely on the heels of new plans from CVS Caremark Corp. and Walgreens Co.—both introduced this month–and Wal-Mart Stores Inc., which launched its plan with Humana last year.

Like Humana has done with its low-cost Walmart-Preferred Rx Plan, big chains such as Rite Aid and Walgreens are trying to lure seniors into their plans by advertising either low monthly premiums, low co-payments, or even $0 co-payments for generic drugs. One of the reasons they can charge such low prices is because it’s a great way to fill as many prescriptions as possible and get more shoppers into their stores to buy other products.

The catch for the consumer, though—of course there’s a catch—is that these drugstore-sponsored plans have highly restrictive pharmacy networks. If you purchase your drugs from a pharmacy that is not in the network, you will more than likely have to pay more than what is advertised in the large print.

A $10 co-payment is not the same as a $1 co-payment.

For example, if you go to the website for Humana’s Walmart-Preferred Rx Plan, you will see that the plan offers a $1 co-payment for preferred generics. However, read the fine print, and you’ll discover that in order to pay only $1, you have to use a preferred pharmacy, which includes, surprise, surprise, pharmacies at Walmart, Walmart Express, Sam’s Club, and Walmart Neighborhood Market. The price jumps to $10 if you use any other pharmacy in the restricted network. For preferred brand-name drugs, you’ll pay a 20% coinsurance if you use a Walmart pharmacy, but almost double (37%) anywhere else within the network.

How close is a large chain pharmacy to your home?

Last year, despite my objections, a family member enrolled in the Humana plan. She loved the low monthly premium, but she hated that she would have to use a Walmart pharmacy to get the best prices for her medications. The closest Walmart is about 25 minutes from her home, so not only does she have to pay extra for gas, but it takes her more than an hour to get there and back by the time she parks and waits on line. (I’m still trying to convince her to switch to the mail-order pharmacy!)

The moral of this story is two-fold: Always read the fine print whenever you are comparing prescription drug plans, and make sure that your local or favorite pharmacy is a preferred pharmacy in the plan’s network. Large, national prescription drug plans from companies like Blue Cross Blue Shield, Medco, or Wellcare may have higher premiums, but if you prefer using a smaller retail pharmacy in your hometown, your total costs may even out in the end.

Reminder: Open Enrollment is now through December 7, 2011.

Post Navigation

%d bloggers like this: