AMCP Prepares Detailed Summary of CMS 2017 Draft Call Letter

ALEXANDRIA, Va., February 24, 2016 - The Academy of Managed Care Pharmacy has prepared a detailed summary of the 2017 Draft Call Letter released Feb. 19 by the Centers for Medicare and Medicaid Services (CMS). The annual CMS notice includes proposed changes in payment methodologies for Medicare Part D benefits and annual adjustments to the Medicare Part D benefit parameters for the defined standard benefit.

AMCP is pleased to see that CMS acknowledges AMCP in the Draft Call Letter, and credits the work that AMCP’s Medication Therapy Management Advisory Group is doing to develop a framework to define drug therapy problems. AMCP will continue to collaborate with stakeholders in this area, such as PQA and the HIT Collaborative, to develop a standardized framework to allow for the shift towards outcomes-based measurements in Medicare Part D.

To access the full AMCP summary and the call letter, visit here.

The following are areas of specific importance to AMCP that it is seeking feedback on from stakeholders:

Tiers & Specialty Medications:  

  • CMS proposes applying the annual percentage increase used in the Part D benefit parameter updates to the existing $600 specialty tier threshold. Thus, for CY 2017, the specialty tier cost threshold will be $670. CMS states that it may or may not increase the threshold on an annual basis moving forward and that it will test the proposed increased threshold and continue to perform other analyses to assess whether threshold adjustments are necessary.
    • AMCP seeks comments on how the change in specialty cost threshold will affect benefit design, including if certain medications may no longer be eligible for consideration on a specialty drug tier given the increase in threshold. 
  • CMS proposes a non-preferred drug tier option that will allow for a drug mix regardless of brand/generic status. If approved, sponsors will have the option of selecting a non-preferred drug tier or non-preferred brand tier but not both. CMS encourages Part D sponsors to consider using a coinsurance for the non-preferred drug tier instead of a copay. 
    • AMCP seeks comments on this proposal and the impact it would have on benefit design, including CMS’ recommendation that Part D sponsors consider using a coinsurance vs. a copay. 
Formulary-Level Cumulative Opioid POS Edits:
  • CMS expects that sponsors who adjudicate pharmacy claims at POS will implement formulary-level cumulative MED POS edits effective January 1, 2017.PACE organizations that do not adjudicate claims at POS are exempt from this expectation. In order to minimize claim rejections on false positives, CMS proposes that sponsors implement both soft and hard cumulative MED POS edits. 
  • CMS will not establish the cumulative MED levels, rather sponsors’ Pharmacy and Therapeutics (P&T) committees will develop the specifications for the soft and hard cumulative MED POS edits. 
  • Beneficiaries with certain conditions, such as cancer, or those in hospice, would be exempted from the edits. 
  • AMCP seeks comments on the proposed parameters for formulary-level cumulative MED POS edits, including alternative thresholds, criteria to reduce false positives, and methods to assure prompt access to prescribed opioids when determined medical necessary.
Star Ratings & Display Measures:
  • CMS does not propose new star ratings for 2017, but proposes several display measures for 2017 and beyond, including: 
    • Post-discharge medication reconciliation; 
    • Hospital readmissions for certain conditions; 
    • Medication utilization in asthma, cardiovascular disease, and diabetes; 
    • Care coordination;
    • Appropriate pain management;
    • Use of antipsychotics in dementia;
    • Depression treatment; and,
    • Evaluation of certain existing measures.
  • CMS proposes the removal of two measures from the 2017 Star Ratings:
    • High risk medication; and 
    • Improving bladder control. 
  • AMCP provided detailed comments to CMS in response to the memorandum titled “Request for Comments: Enhancements to the Star Ratings for 2017 and Beyond” in December 2015 outlining the Academy’s position on several of the proposed changes to the Star Ratings and display measures for 2017 and beyond. AMCP is pleased to see that many of its concerns were addressed in the Call Letter and that no drastic changes to the Star Ratings or display measures are being proposed for CY 2017. AMCP will reiterate these comments in its response to the Call Letter. 

Enhancements to Medication Therapy Management (MTM): CMS seeks to improve comprehensive medication review (CMR) completion rates and will continue to seek additional outcomes measures. AMCP is working with CMS and other stakeholders, including the Pharmacy Quality Alliance (PQA) and the HIT Collaborative to evaluate Medicare Part D MTM, electronic coding, and the development of outcomes measures.

CMS Audits of MTM Programs: CMS proposes that program audits will soon include review of Part D sponsors’ MTM programs to determine bias outside of the Data Validation results such as attempts to restrict eligibility from approved MTM programs, encouraging beneficiary opt-out of MTM programs within the first 60 days, or comprehensive medication reviews (CMRs) that do not meet CMS’ definition per guidance. AMCP seeks input from members and stakeholders regarding the scope of these audits. 

Point of Sale (POS) Pilot: CMS seeks feedback on a point of sale pilot it conducted, specifically on the value of electronic prescribing, electronic prior authorization (ePA), formulary access by prescribers, and other approaches to reduce POS rejections. AMCP has actively promoted efforts to adopt the ePA standard approved by the National Council of Prescription Drug Programs (NCPDP) as a way to improve efficiencies in the PA process. Furthermore, AMCP seeks to increase the adoption of e-prescribing of controlled substance prescriptions. AMCP will provide feedback and comments on these initiatives.

AMCP will submit comments to CMS by the March 4 deadline.