E&C Adds Beneficiary Appeals To Lock-In Pharmacy Measure In Cures Bill

DATE: May 11, 2015

House Energy & Commerce members added a beneficiary-appeals measure to a provision in 21st Century Cures draft legislation that would let plans limit which pharmacies may dispense drugs prone to abuse, such as pain medicine; but seniors’ advocates and independent pharmacies say the committee didn’t significantly amend the pharmacy-network provision and the language could make it difficult for beneficiaries to obtain medicine they desperately need.

The Ways & Means Committee also crafted a legislative proposal on narrow pharmacy networks for drugs that are commonly abused, and seniors’ advocates said that provision, which was part of the Protecting the Integrity of Medicare Act, goes further to protect beneficiaries. All but the pharmacy lock-in measure of that bill was included in legislation replacing the Sustainable Growth Rate formula.

“We continue to believe the Protecting the Integrity of Medicare Act (PIMA) offers the best language and most robust beneficiary protections of any of the Part D lock-in models we have seen,” said Stacy Sanders, federal policy director for the Medicare Rights Center. “Importantly, PIMA provides clear direction to HHS to ensure the lock-in program is narrow and targeted. It also includes important provisions on notice to beneficiaries, plan communication with prescribing doctors, carve outs for hospice and cancer patients, a mechanism to protect beneficiary choice and more.”

Pharmacy benefit managers and managed care pharmacies, which like the provision, call it the “safe pharmacy program,” and independent pharmacies dislike it and refer to it as “pharmacy lock-in.” Everyone supports the goal of curbing prescription drug abuse, but they disagree over whether the pharmacy-network provision would limit access for beneficiaries with legitimate prescriptions.

Alan Rosenbloom, president and CEO of the Senior Care Pharmacy Coalition, said long-term care pharmacies, which serve nursing homes and other long-term care facilities, should be exempt from the rules on safe-pharmacy networks for several reasons. Most importantly, the retail pharmacies chosen for safe-pharmacy networks would not be able to serve nursing homes because long-term care pharmacies operate under special Medicare regulations, and it’s not clear how nursing home residents would get restricted medications in those situations. Even if plans were to try accounting for nursing homes, seniors might be in a safe-pharmacy network before being admitted to facilities, delaying the delivery of medications once they are admitted. Nursing homes contract with pharmacies, so another problem arises when the long-term care pharmacy in a safe-pharmacy network isn’t the pharmacy that a nursing home uses, which could lead to limiting seniors’ choice of nursing homes.

Also, long-term care pharmacies operate under regulations that are stricter than those the bill would apply to safe-pharmacy networks, Rosenbloom said, so it shouldn’t be a problem to exclude them. Further, nursing home residents are unlikely to be the ones tricking multiple pharmacists into filling the same prescription, he said.

National Community Pharmacists Association spokesman Kevin Schweers said, even outside long-term care facilities, seniors who legitimately need pain medicine often have a difficult time obtaining it because of existing restrictions on many pain medications. Schweers said the measure gives plans and pharmacy benefit managers too much control. Pharmacy benefit managers would be allowed to set up networks of pharmacies they either own or have business relations with, cutting out independent pharmacies. He added that, if the measure is retained, it should at least add restrictions on physicians because prescription drug abuse starts with prescriptions.

The Pharmaceutical Care Management Association, which represents pharmacy benefit managers, did not talk toInside Health Policy for this story, but it issued a release stating that the key to stopping drugstore shopping is preventing improper prescriptions from being filled in the first place.

“A ‘Safe Pharmacy’ program will save lives and money by ensuring that at-risk patients only fill prescriptions for opioids and other addictive drugs at high-quality pharmacies that are equipped to prevent fraud and abuse.

The National Association of Chain Drug Stores wants the committee to let beneficiaries select pharmacies with multiple locations.

“This will allow a beneficiary to obtain their medications from a number of locations for a particular pharmacy, so long as that pharmacy uses a common database that would ensure medications are not inappropriately dispensed,” the organization states in comments to the committee. “Similarly, processes must be in place to ensure that beneficiaries can quickly change their selection when they move.”

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