Peter J. Kounelis, R.Ph., Vice President Elevate Provider Network
One of the fundamental provisions of the Medicare Part D program is that any pharmacy provider can participate in all Part D networks at the Standard Cost Share level, as long as they accept and meet each plan sponsors’ standard terms and conditions. This is applicable whether a pharmacy contracts through a PSAO, or whether they contract directly with a particular plan sponsor. The plan sponsor must offer, or at least provide upon request, these standard terms and conditions, and then include any providers that comply into their network. This ensures that “any willing pharmacy” can continue to see all of their Part D patients.
In fact, CMS issued guidance on Part D’s, “Any Willing Pharmacy,” requirement specifically:
Section 1860D-4(b)1)(A) of the Social Security Act (“the Act”) requires a Part D prescription drug plan to permit”the participation of any pharmacy that meets the terms and conditions under the plan.” The Part D regulations at 42 C.F.R. § 423.120(a)(8)(i) require that Part D sponsors “must contract with any pharmacy that meets the Part D sponsor’s standard terms and conditions.” CMS further notes in Chapter 5 of the Medicare Prescription Drug Benefit Manual, Section 50.8.1 that, ” ‘Any willing pharmacy’ refers to the requirement that Part D sponsors permit the participation in their Part D plan networks of any pharmacy . . . that is willing to accept the sponsor’s standard contracting terms and conditions.” CMS further states in the same section that the standard terms and conditions must be “reasonable and relevant.”
To comply with the Any Willing Pharmacy requirement, a Part D plan sponsor must make standard terms and conditions available for all Part D plans it offers. For those terms to be reasonable and relevant, they must identify for the pharmacy the plan(s) to which they apply, and the offer must include language that obligates the Part D sponsor to include the pharmacy in the identified plan(s) upon the pharmacy’s acceptance of the terms and conditions.
Source: CMS Compliance with Any Willing Pharmacy (AWP) Requirements
While the offer at the Standard Cost share (low or no DIR) must be extended to all, conversely, the offer to participate as a Preferred Cost Share (higher DIR fee) provider is optional for both parties. An option that Elevate Provider Network carefully considers when negotiating on behalf of our members. We are committed to preserving all of your patients’ ability to continue receiving unparalleled good service at your pharmacy, while protecting your ability to continue to provide it by agreeing to only those DIR fees that make sense. (Remember, another tenet of Med D-patients pick their plan and they pick their pharmacy.)
“I have been very impressed with Elevate Provider Network’s Med D contracting this year. We have gained volume and our reimbursement is up!”—David Belew, Belew Drug Family of Pharmacies, Knoxville, TN
Driven by our proprietary pharmacy analytics system, we model and negotiate smarter payer contracts based on our long-term strategy for managing the impact of preferred cost-share (higher DIR) networks. We’re driven by the data when considering which plans we join at the preferred or the standard cost-share level, and that clear objectivity helps us protect your independence by protecting your margins.
