Phase III of COVID-19 Stimulus Package May Affect Pharmacies Filling Medicare Prescriptions

By Jonathan L. Swichar, Bradley A. Wasser and Coleen W. Hill

Phase III of the Covid-19 stimulus package may affect pharmacies filling Medicare prescriptions in various ways.

First, the stimulus package requires Medicare Part D and Medicare Advantage plans to allow for fills or refills of up to 90 days during an emergency period, unless the drug has prohibited such refills through a safety edit.  As a result, pharmacies will be able to fill the Medicare Part D and Medicare Advantage plan prescriptions for 90 day periods, which should help reduce the number of pharmacy visits for the patient and reduce refill efforts for the pharmacies.

Second, the stimulus package suspends the federal budget sequester for Medicare payments, which reduces payments to providers by 2 percent, from May 1, 2020 to December 31, 2020.  This suspension will cause an increase in Medicare Part B reimbursement to providers, including raising payments for drugs from average sales price plus 4.3% to an average sales price plus 6%.

Third, the stimulus package requires rapid coverage of preventative services and vaccines for private insurers.  In essence, the stimulus package directs private insurers offering individual and group plans to provide coverage without cost-sharing of a COVID-19 vaccine or other certain preventive services.  In addition, the stimulus package requires Medicare Part B coverage of a Covid-19 vaccine, consistent with the treatment of flu and pneumococcal vaccines.  Given these adjustments, pharmacies may begin to see an increase in fill requests for these products.

Although not addressed by the Covid-19 stimulus package, pharmacy benefit managers (“PBMs”) are allowing pharmacies to participate in certain insurance networks for which they have not yet been approved in the midst of the Covid-19 crisis.  In short, PBMs operate as the “middle-men” between insurance payors and pharmacies to contract with insurance companies, establish pharmacy networks for patients under insurance plans, and set the reimbursement rates paid to pharmacies for providing pharmacy services to insureds.  At this time, many PBMs are offering pharmacies, who are not admitted in a particular network, blanket overrides to fill medications for patients in that network who request those prescriptions from the out-of-network pharmacies.  For example, PBMs are allowing pharmacies who have not been admitted into in a particular mail network to fill prescriptions for patients in that network and mail those prescriptions to the patient.  These blanket overrides from PBMs should function to help pharmacies fill and refill patient prescriptions in the safest and fastest manner to ensure that all patients receive the medication needed during this crisis.

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The opinions expressed on this blog are those of the author and are not to be construed as legal advice.

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