March 22, 2022
NHIA submitted comments on a CMS proposed rule: Medicare and Medicaid Programs; CY 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs, which would alter the way pharmacy price concessions, including direct and indirect remuneration (DIR fees), are calculated by pharmacy benefit managers (PBMs).
According to CMS, the changes outlined in the proposed rule are intended to achieve the goals of meaningful price transparency, consistent application of all pharmacy payment concessions by all Part D sponsors, and to prevent cost-shifting to beneficiaries and taxpayers. In addition, the agency wanted to address an unsustainable increase in DIR fees and the small percentage of price concessions being passed through to beneficiaries at the point of sale.
While NHIA supports CMS’s efforts to address the abusive practices of PBMs surrounding DIR, the association expressed concerns that unless all pharmacy price concessions are accounted for at the point of sale at the claim level, PBMs could restructure pharmacy fees to circumvent the intent of the proposed rule. NHIA also opposes allowing for an “alternative negotiated price” for drugs in the coverage gap and requests that CMS apply the proposed revised definition of negotiated price consistently throughout the Part D benefit, which would benefit Medicare beneficiaries.
On December 2, 2022, NHIA sent a follow-up letter to Defense Health Agency, including a copy to Express Scripts (ESI), sharing recent updates on efforts by ESI to narrow the TRICARE pharmacy network and urging the DOD to reinstate all home infusion providers to the ESI network to prevent disruptions in home infusion access for TRICARE beneficiaries.
A diverse group of 30 patient and stakeholder groups are calling on Congress to address Medicare beneficiary access to home infusion services. In a letter to lawmakers, which brings together stakeholders from across the care continuum, the groups urge congressional leaders to advance the Preserving Patient Access to Home Infusion Act (S. 2652/H.R. 5067) and increase access to home infusion therapy for Medicare beneficiaries.
NHIA member pharmacies began reporting that TRICARE patients had received letters from Express Scripts stating the local home infusion pharmacy they currently use will not be in network as of October 24, 2022. NHIA sent a letter to Defense Health Agency and Express Scripts requesting the repeal of any network pharmacy cancellations.
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