While the annual CMS Call Letter for 2018 revealed no major surprises or large changes anticipated for 2018, there were definitely some highlights that should be noted. As always, your Visante team of experts is prepared to support you in your compliance goals.

 Social Security Number Removal Initiative (SSNRI)

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 included a mandate to remove the current Health Insurance Claim Number (HICN) from Medicare cards. In 2018, the HICN will be replaced with a new Medicare Beneficiary Identification number (MBI). All Medicare recipients will be assigned an MBI number, and cards with this information will be mailed to beneficiaries in April 2018. Plan Sponsors will need to be able to process enrollments using either the HICN or the MBI and also ensure that other processes, such as Coordination of Benefits, Appeals etc. are not impacted. For further information, CMS provides a Social Security Number Removal Initiative (SSNRI) webpage https://www.cms.gov.Medicare/SSNRI/Index.html.

Tiering Exceptions: Policy Clarifications and Additional Operational Guidance

CMS clarified that tiering exceptions are to be considered when the applicable alternative drug(s) is/are on a formulary tier that has a lower cost-share than the tier of the requested drug — thus making it “preferred” — and should not be based on the label of the tier containing the alternate drug. Therefore, when a Plan Sponsor approves a tiering exception request in situations where there are alternative drugs in multiple lower tiers, it must apply the cost-share of the lowest applicable tier that contains alternatives for the requested drug. However, plans may restrict approving any tiering exception at the tier cost-sharing level that applies to generic drugs, for those tiers only containing generics (not mixed tiers that include both brand name and generic drugs). For purposes of tiering exceptions, CMS also clarified that “authorized generics” are to be considered generic drugs.

Improving Drug Utilization Review Controls in Medicare Part D

CMS introduced the Drug Utilization Review Controls for CY 2013. Since its inception, CMS has made changes each year to further fine tune the program. This year is no exception. CMS is revising the Overutilization Monitoring System (OMS) criteria for Plan Year 2018. Below are the new parameters. CMS will follow-up with a revised analysis summary at https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/ RxUtilization.html

  • During the most recent six months,
    • Beneficiary use of opioids with an average daily morphine equivalent dose (MED) greater than 90 mg for any duration; and
    • Received opioids from more than three prescribers and more than three pharmacies, OR from more than five prescribers regardless of the number of opioid dispensing pharmacies.
    • Beneficiaries with cancer diagnoses and beneficiaries in hospice are excluded.
    • Prescribers associated with the same single TIN are counted as a single prescriber.

Also in 2018, Part D Plan Sponsors are expected to lower their internal criteria to be no less restrictive than the use of opioids with an average daily MED exceeding 90 mg for any duration during the measurement period. Plan Sponsors have the option to use a lower MED threshold and may vary other criteria as well, including the number of prescribers and pharmacies. Sponsors also have the flexibility to apply other methods to group prescribers within the same practice or not, as some sponsors do not have access to the TIN.

Lastly, the proposed formulary-level hard edit regarding real-time Safety Alerts at the Pharmacy was not finalized for the 2018 Plan Year. The opioid safety edits based on cumulative MED can continue to be either a hard or soft edit.

If you are new to the OMS program, the 2018 CMS Call Letter provided a lot of background information that is recommended reading.

If you need any assistance with this new guidance or other Medicare Part C / D services, we are here to help! Please contact us at solutions@visanteinc.com.

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