October 6, 2009

Texas Pharmacy Business Council is an organization of American Pharmacies and the Academy of Independent Pharmacists-Texas.
www.TxRxCouncil.org

Tamiflu compounding issues prove how inflexible PBMs are

Don't give PBM lobbyists the last word!

Possible DMEPOS accreditation delay

CMS investigates 'scare tactics' Humana letter

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	Texas legislation success list
REGULATION OF Rx DISCOUNT CARDS PBM TRANSPARENCY IN STATE CONTRACTS MAIL ORDER PARITY

Tamiflu compounding issues prove how inflexible PBMs are

Even when presented with a physician's prescription and FDA guidelines explaining how to compound Tamiflu suspension and why compounding is necessary, PBMs held fast to their inflexible reimbursement rules. The past few weeks have been difficult at best for those of you faced with the conundrum of footing the bill for patients whose sick children needed liquid Tamiflu and who could not afford the extra cost. The alternative, sending patients away with no Tamiflu, was reprehensible for humanitarian reasons.

When some of you called the Council to ask how to remedy the situation, we started looking into it. One of the actions we took was to call a representative sample of chain drugstores in the Austin area, including Costco, CVS, Walgreens, and Walmart. Our caller, a female, asked whether the pharmacy had liquid Tamiflu. When told no, she begged them for a suggestion on how to get the Tamiflu for her child.

Only one store, where the person on the phone was a pharmacist and not a tech, showed any concern, and it was half-hearted at that. His suggestion was to try one of the 24-hour stores. and that she would probably have to wait a while. Well, as we all know, timing is everything with Tamiflu.

Another suggestion was to pour the capsule into applesauce. Right! Expecting a non-pharmacist to take a 75mg capsule and only pour "x" amount of it on food is a farce! It's obvious that only independent community pharmacists can adapt quickly when compounding is the only recourse.

Another interesting twist to this problem is the fact that CVS Caremark and WellPoint were not nimble enough to accommodate the situation, even as their computers had to be registering the requests and denials.

This is the kind of bureaucracy in the health care system that stresses out pharmacists and causes mothers to weep.

Pharmacist members of the Council received a survey yesterday asking about your experiences with this matter. PLEASE take a few minutes to fill it out and send back. We kept it brief because we know how busy you are. This information is important to our ongoing legislative issues as well as writing news releases and distributing to reporters who cover medical issues.

This has been going on for a few weeks now. The FDA released 117,000 doses from federal stockpiles to the Texas Department of State Health Services, which in turn distributed it to Federally Qualified Health Centers. According to my discussion with TDSHS, this is to be used for uninsured and underinsured individuals. We haven't figured out yet how that determination is being made.

The FDA surprised us late Friday with an authorization to use expired lots of liquid Tamiflu! The expiration dates went back to 2005. My question is "How many of you have been squirreling away liquid Tamiflu?" That's only a rhetorical question. I know you have complied with federal and state laws making it impossible to have expired medications.

So my next question is "Do you suppose the mail order pharmacies have been hanging onto doses?"

This is just gallows humor, folks. The reality is we have a problem that is only going to get worse as this seasonal and H1N1 flu spreads. We want to spread the word about how the PBMs are adding to the burdens of this flu season.

Please document as much as you can. We're particularly interested in how Caremark is handling this because it is the PBM for the Texas Employees' Retirement System. Recent legislation and the ERS's own interest in making sure its beneficiaries are treated well makes the information you can provide us all the more important.

So, please, fill out the survey! And continue to take note of how this situation evolves.

Stay tuned!

Richard E. Beck, RPh
Executive Director, Texas Pharmacy Business Council

Don't give PBM lobbyists the last word!
Urge Cornyn & Hutchison to support PBM transparency in health reform

Well-funded PBM lobbyists are blanketing Congress with lies and deception. Call Senators Cornyn and Hutchison TODAY to ensure final Senate health reform legislation includes critical provisions requiring PBMs to disclose their enormous fees. This legislation will achieve a new level of transparency that will help plans keep premiums and out-of-pocket expenses down for your patients.

Transparency helps reduce drug costs, but there is no meaningful federal or state requirement that PBMs disclose to public or private payers how they conduct business.

The facts speak for themselves:
PBMs are driving up health care costs by billing plan sponsors much more than they reimburse pharmacies and keeping large shares of manufacturer rebates, among other practices. We need to ensure our patients receive the drugs they need at a fair price.

It is only through transparency that health plans will be able to confirm a PBM is securing the lowest drug costs, and to make sure PBMs operate within the interests of the patients and health plans they are meant to serve. We need to ensure your lawmakers know the facts.

Please contact your Senators today. Call Sen. Cornyn at (202) 224-2934. Sen. Hutchison's phone number is (202) 224-5922. Light up the switchboard!

And as usual, we would appreciate knowing how many of our Texas pharmacists, their friends, their family, their patients....well, you get the idea. Let us know how many of you called your U.S. Senator.

Possible DMEPOS accreditation delay

The deadline has come and gone for pharmacies to obtain CMS accreditation to bill for DMEPOS. There is a possibility Congress will extend that deadline to Jan. 1, 2010. However, we expect Congress to pass some form of DME accreditation modification for pharmacies before that date.

That could obviate the need for pharmacies to meet the existing accreditation standards, which many pharmacies have found to be costly and burdensome.

The House passed the deadline extension, but the Senate has not yet acted. They are likely to act next week.

Because the extension is likely to pass this week, CMS advises us that pharmacies, under certain circumstances, can continue to bill for DMEPOS.

Here is the the situation as we know it:

Those pharmacies that have obtained accreditation and a surety bond can continue providing Medicare Part B drugs, vaccinations, and DMEPOS.
If a pharmacy voluntarily terminated from the Medicare Part B program OR has "stepped down" on their 855S forms (that is, indicating that the pharmacy would be providing only Part B drugs BUT not DMEPOS) and the National Supplier Clearinghouse has processed your application, you are NOT able to bill for DMEPOS, even if the extension passes this week.
A pharmacy should receive a confirmation letter from NSC regarding their change in status. If your "stepped down" application has been processed, UNLESS you modify your 855S again to indicate that you also will dispense Medicare DMEPOS in addition to Part B drugs, you cannot provide DMEPOS, even if the extension passes. Processing these applications could take some time, so although you would be able to bill again for DMEPOS, but it may take several weeks for CMS/NSC to process the "step up" application.
If you have "stepped down" and are waiting for accreditation, CMS says your billing privileges exist as of the date on the accreditation certificate.
If a pharmacy voluntarily terminated from Medicare Part B OR has "stepped down" on their 855S form and NSC HAS NOT processed your application, you can continue to bill for DMEPOS and Part B drugs. NSC will not process that application. The key is KNOWING whether the application has been processed. NCPA secured a commitment from CMS that CMS will ask the NSC to NOT process any more pharmacy applications that request a "step" down or voluntarily termination from the program. Therefore, if you submitted either form within the last few days, it is not likely it has been processed. If your application has not been processed, CMS says you can continue to bill for Part B drugs and DMEPOS, assuming you have a surety bond.
If you want NSC to process the application to step down or voluntarily terminate, then CMS is going to ask pharmacies to send a letter to the NSC, asking that they process the application. Pharmacies also can call the NSC to see if their application has been processed, but it may take some time to get through given the number of calls going into the NSC.
AS ALWAYS, YOU MUST OBTAIN A SURETY BOND TO CONTINUE TO BILL MEDICARE PART B FOR EITHER DRUGS, VACCINATIONS, OR DMEPOS!!! You only need a surety bond to bill for Medicare Part B drugs/vaccinations if you are not billing for DMEPOS. CMS says they will give SOME flexibility to pharmacies on getting the surety bonds in October--days, not weeks. So, get it in as soon as you can!!!

The NCPA is hopeful the Senate will pass the extension this week. One caution: If for some reason the Senate does not pass the extension, then existing law remains. Pharmacies need to be accredited to sell DMEPOS.

CMS investigates 'scare tactics' Humana letter

Humana appears to have stepped over the line with a letter sent to beneficiaries about health reform. CMS has launched an investigation. Officials are looking into whether Humana used scare tactics when it reached out to Medicare Advantage members and took a stand on health reform legislation.

In the letter, Humana allegedly claims that current health reforms could hurt millions of senior and disabled individuals by taking away important benefits and needed services. The letter is a possible violation of federal regulations, CMS leaders said.

CMS ordered Humana to stop sending out such letters. It's also sent out its own warning to every health plan that sells Medicare Advantage coverage, as well as those selling drug plans, informing execs that they could face legal penalties if they send out letters attempting to scare seniors into taking a health reform position.

The impetus for the CMS investigation came from Sen. Max Baucus (D-MT), who has spoken harsh words about Humana and any other insurer that might get mixed up in health reform politics.

This reminds us of the unauthorized attempt to force Texas Employees Retirement System beneficiaries to use mail order for maintenance meds. They sent the letter Christmas Eve last year, and ERS quickly forced them to send a retraction letter. It seems PBMs believe the old adage that it's easier to apologize than to ask for permission.

Texas Pharmacy Business Council
Ensuring patient access to quality pharmacy care services,
the viability of community pharmacy and the pharmacy profession.
1001 Congress Ave., Suite 250, Austin, TX 78701 512.992.1219
Richard E. Beck, RPh, Executive Director
www.TxRxCouncil.org