The CMS 2016 Medicare Advantage & Prescription Drug Plan Spring Conference and Webcast was held on May 5th, 2016. In case you missed it, here is a brief summary of some of the information shared.

I.  Updates for PDBM Chapter 6: The Part D Formularies Awaken

Beginning with a review of the history and timeline of Chapter 6, CMS discussed the January 2016 updates. Using current regulations, Call Letters and CMS memos, tempered by various stakeholders’ feedback, they feel that Chapter 6 is now streamlined and has important cross-references to related policies and regulations, which will reduce redundancy.

New Areas Covered in the 2016 Chapter 6 Revisions

  • Commercially available combination products covering broad distribution are now included.
  • Extemporaneous compounds, such as those that are ingredient-specific considerations, are covered for Part D and formulary status.
  • Medically accepted indications for medication use are now required to be supported by CMS-recognized compendia when determining medically accepted indications for use and should include prior authorization (PA) or other similar reliable tools for determining appropriate drug coverage.
  • Retrospective determination of a medically accepted indication of use. This will allow for the deletion of PDEs and accumulator adjustments when their use is determined to be of a non-medically accepted nature.
  • A summary of excluded categories and drugs covered under Parts A or B versus Part D and the application of PA under specific circumstances.
  • Review of CMS policy on formulary changes and required advance notice for negative changes including exception expirations and transitions. This includes provider notice of transition fills and sample transition scenarios.

Frequently asked formulary questions were responded to by CMS concerning quantity limits (QLs), formulary updates, the Formulary Reference File (FRF) (new QL units on the FRF for 2017), and updates for utilization management (UM) criteria. It was clear from these questions that some plans are still struggling to attain, or maintain, compliance in formulary and benefit administration.

II.  Effective Strategies for Addressing Overutilization and Abuse of Prescription Drugs Under Medicare Part D

This presentation covered some changes for 2017 in the Overutilization Policies. For Level 1 – Concurrent Claim Edits, all Plan Sponsors are expected to implement soft and/or hard formulary-level cumulative opioid morphine equivalent dose (MED) edits at POS with appropriate exclusions (e.g. with cancer or hospice care). CMS recommends a hard edit for at least 200 mg MED and/or a soft edit for no lower than 90 mg MED. This recommendation also includes using a prescriber count criterion of at least two prescribers and should not reject drugs used for the treatment of opioid use disorder.

Additional changes for 2017 include:

  • Timely submissions of beneficiary-level opioid POS edit data to MARx within 7 business days.
  • Maintaining formulary access to medication-assisted treatment for opioid use disorder.
  • Eliminating a sponsor’s utilization management process that may lead to inappropriate use of methadone in pain management.

III.  PBM Migration: Lessons Learned in Part D

CMS and WellCare presented information relating to WellCare’s recent migration to a new Pharmacy Benefit Manager (PBM). This session was intended to help other plans as they undertake a significant change that will affect their Part D beneficiaries. WellCare shared aspects of its work plan involving both internal and external parties including CMS, their outgoing PBM, and their incoming PBM. WellCare also outlined important lessons learned, its biggest challenges, as well as what worked well in this transition.

Project communication was identified as one of the primary success drivers. They also learned that early and frequent communication with both the central and regional CMS offices, transparency internally and externally, and candid discussions with peers who have previously gone through this process previously were important to the project’s success. Having full CMS engagement provided important insights, recommendations and helpful ideas throughout the migration. Executive support and commitment from both WellCare and its PBM were also a key factor in their success. This high-level support provided early insight into issues and facilitated joint participation when defining the plan to address those issues and risks.

Another success factor for WellCare was the result of using proactive disruption analysis. WellCare prepared a detailed analysis of its formulary utilization and pharmacy use. Then they made changes to their formulary in the 4th quarter to facilitate a smoother transition into the new year. In conjunction with this, WellCare created a robust communication strategy for notification of those individuals who would be impacted by the approaching change. This included many touches to affected beneficiaries, targeted and customized letters to members, focused pharmacy and provider communications, as well as communication with patient advocates, legislators, and other interested groups.

IV.  Combating Fraud, Waste and Abuse in Medicare Parts C and D

This presentation was divided into three sections:

An overview of the current FWA situation.  Drug Diversion is still the number one investigation type at 31%, followed by Billing for Services Not Rendered (19%) and Misrepresenting Services/Products (14%). Genetic Testing Fraud Schemes was an interesting topic for fraud. This involves billing for medically unnecessary genetic tests without specified medical conditions or physician orders. Beneficiaries are targeted at senior living housing locations where they provide their Medicare numbers. Labs use their Medicare number and other personal information to do this genetic testing

Information on the PLATO system to be used for FWA.  PLATO is a system that will be used for fraud detection and tracking outcomes. The users of the PLATO system include CMS, law enforcement, NBI MEDIC and Plan Sponsors. It is a web-based tool that has search, filter and analysis capabilities (for more information There are currently more than 700 PLATO users with over 3100 activities.

Plan Sponsor self-audits.  This process will be initiated when Plan Sponsors receive an engagement letter as notice of this audit. The engagement letter will include the contracts under review, the review period, drugs under review and the overall audit process. The self-audit has two phases: a webinar review of selected PDE records and a self-audit to be performed by the Plan Sponsor. CMS will request documentation to support coverage and payment decisions for the samples reviewed during the final webinar. For all inappropriate payments identified, Plan Sponsors will be required to delete the associated PDE records.

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