Medicare Part D

AMCP supports the ability of managed care organizations to selectively contract with only those providers necessary to enable the organization to provide patients with adequate access to pharmacy services and quality, cost-effective health care. By selectively contracting with providers, managed care organizations assure that patients can receive the best care, have access to the providers they need and reduce the likelihood that valuable health care resources will be wasted through inappropriate use. Therefore, the Academy opposes legislation that would require managed care organizations to contract with any provider meets the terms and conditions of the organization, whether or not it can be shown that the provider meets the geographic access needs and/or quality standards of the health plan.

 
(See AMCP Managed Care Pharmacy Practice Positions - Any Willing Provider Legislation)

AMCP supports the inclusion of prescription drug coverage in all health care benefit programs, including those administered by the government (e.g., Medicare, Medicaid, health insurance exchanges). Access to and proper utilization of a comprehensive prescription drug benefit, have been shown to reduce the severity of and complications arising from many common illnesses. Failure to provide prescription drug coverage can increase the use of more intensive, costly health care services, such as surgery and/or hospitalization. AMCP also supports granting flexibility to managed care organizations to develop clinically sound, evidence-based benefits free from arduous mandates.  
 
(See AMCP Managed Care Pharmacy Practice Positions - Prescription Drug Coverage)

Development of Performance Measures

Policy 0006

02/01/2000 Introduced
02/01/2005 Revised
11/01/2009 Revised

02/21/2018 Revised

Government-Mandated Pharmacy Benefits

Policy 0101

03/01/2001 Introduced
06/01/2006 Revised

02/13/2019 Reapproved

AMCP supports the right of managed care organizations and their clients to independently make decisions with regard to health benefits that meet the medical needs of specific patient populations while being compassionate, medically sound, timely, and fiscally responsible. Federal and state legislation and regulations should not hinder a health care delivery system's ability to provide customized benefits that assure value and quality patient care for specific patient populations, yet remain affordable.

(See AMCP Managed Care Pharmacy Practice Positions - Government-Mandated Pharmacy Benefits)

Patient Satisfaction

Policy 0116

11/01/2001 Introduced
02/01/2006 Revised
12/01/2010 Revised

04/07/20/15 Reapproved

Fraud, Waste and Abuse in the Medicare Part D Prescription Drug Benefit

Policy 1002

06/01/2010 Introduced

03/25/2019 Revised

AMCP is concerned about reports of fraud, waste and abuse within the prescription drug benefit. Fraud, waste and abuse are unacceptable within any health care system, and result in unnecessary payments and costs to patients and public and private payers. AMCP supports efforts that would reduce the instance of fraudulent activity, such as lifting the current “any willing provider” requirement and amending current law and allowing plans to suspend payments to pharmacies upon a credible allegation of fraud.

(See AMCP Managed Care Pharmacy Practice Positions - Fraud, Waste and Abuse in the Medicare Part D Prescription Drug Benefit)

Government Regulation of Prescription Drug Prices

Policy 1003

06/01/2010 Introduced

04/12/2021 Revised

AMCP believes that government regulation of prescription drug pricing could result in unintended consequences such as higher costs for patients, payers, and providers. Government-regulated prices could greatly impair the ability of managed care organizations (MCOs) to design a competitive benefit offering that integrates clinically sound, evidence-based medication choices with delivery systems and co-payment alternatives that provide beneficiaries with substantive choice. AMCP works to ensure patient access to medications at an affordable cost and supports working with elected officials and health care stakeholders to develop practical, informed, and market-based solutions to make prescription drugs more affordable and accessible.

 
(See AMCP Managed Care Pharmacy Practice Positions - Government Regulation of Prescription Drug Prices)

Fraud, Waste and Abuse in Prescription Drug Benefit

Policy 1105

10/01/2011

Fraud

• AMCP supports efforts by both federal and state governments that enhance law enforcement’s ability to combat the actions of individuals who falsify prescription information or providers who write prescriptions for patients who intend to abuse the drugs.
• AMCP supports efforts to encourage the adoption of electronic prescribing systems, which could reduce the incidence of fraud at the pharmacy point-of-sale.
• AMCP is opposed to requirements that managed care organizations contract with any pharmacy willing to meet the terms and conditions of an organization’s contract, also known as “any willing provider” requirements. Without such requirements, a managed care organization may refuse to contract with a pharmacy that is suspected of fraudulent activity, such as a pharmacy that files claims and receives payments for prescriptions that are never filled.

Waste

• AMCP supports exemptions from these laws that would allow a health plan or PBM to suspend payment when there is credible evidence of fraud.
• AMCP supports efforts to make generic substitution an easy process for pharmacists and prescribers.
• AMCP opposes regulations that would unnecessarily place a burden on either party in order to make a substitution.
• AMCP supports allowing managed care organizations the flexibility to design pharmacy benefits that encourage the use of therapeutic treatment options that are most appropriate in terms of both patient outcomes and costs to both the patient and payer.

Abuse

• AMCP supports measures to prevent abuse of prescription drugs as well as prescription drug benefit plans.
• AMCP supports programs that gather dispensing information about controlled substances so that the pharmacist has a resource for checking “pharmacy and doctor shopping” patterns.
• AMCP supports sensible changes to current law that would allow Part D plan sponsors to help combat the problem of prescription drug abuse.

(See AMCP Managed Care Pharmacy Practice Positions - Fraud, Waste and Abuse in Prescription Drug Benefits)

Coverage of Drugs under Part B versus Part D

Policy 1303

02/01/2013 Introduced

The administrative burdens resulting from certain medications being eligible for coverage either under Part B or Part D has created confusion, delay and expense for all involved: beneficiaries, Part D plans, providers and the Medicare program itself. The Academy of Managed Care Pharmacy suggests that remedial legislative action on this issue is one of the most important corrective actions that Congress can take as it addresses modifications to the current Medicare Part D program. It is also an issue that can have a dramatic, valuable impact on beneficiary health and well-being, as well as taxpayer savings.

AMCP Recommends:

1. The Academy recommends that the following drugs, which can be self-administered, be moved from Part B, where they are covered in certain situations, to Part D coverage in all situations:

• Oral chemotherapeutics
• Oral anti-emetics
• Inhalation and blood glucose monitoring DME supply drugs
• Immunosuppressants

2. To decrease confusion, all vaccines should be covered under the same part of the Medicare benefit–in this case Part B.

3. The Academy recommends that Medicare Part D plans that have made a coverage determination that can be demonstrated to have been in good faith, and after exercising due diligence, be exempt from legal jeopardy.

(See AMCP’S Medicare Part D Concept Series – Coverage of Drugs under Part B versus Part D)

The Competitive Model

Policy 1305

02/01/2013 Introduced

The Academy of Managed Care Pharmacy (AMCP) supports the continuation of the competitive model for the Medicare Part D program. The Academy supports legislation and regulation that will allow proven private sector best practices to be applied in the public sector.  The Academy will oppose changes to the drug benefit program that would undermine the use of effective managed care strategies.  It will oppose changes that would dilute the competitive structure currently being used for the delivery of the Medicare drug benefit. Additionally, program elements that hinder the use of pharmacy benefit best practices from the private sector should be eliminated.

(See AMCP’S Medicare Part D Concept Series – The Competitive Model)

AMCP believes that government regulation of prescription drug pricing, regardless of its structure, would have an overall negative impact on consumer cost, quality, and access to health care benefits.  Legislation that allows the government to dictate reimbursement terms of a private contract between a payer and a pharmacy or that mandates that the payer disclose proprietary pricing methodology is not an appropriate focus of government regulation.  Further, AMCP believes that competitive negotiations between parties are more likely to provide fair and equitable reimbursement on drugs dispensed.  AMCP does not support the intervention of government into private contracts to require payers to advise pharmacies on where to purchase their drugs; that is an unnecessary and inappropriate intrusion into the private arrangements of a pharmacy with its supplier.  This type of government mandate takes away the incentive for a pharmacy to make wise purchasing decisions.  The payers and consumers will not benefit from a system of government mandated payments to a private entity; rather it will decrease competition and further drive up the cost of the prescription drug benefit.

 
(See also AMCP Managed Care Pharmacy Practice Positions - Government Regulation of Prescription Drug Prices)

Preferred Pharmacy Networks

Policy 1401

07/29/2014 Introduced

The Academy of Managed Care Pharmacy (AMCP) supports the ability of health plans to offer preferred pharmacy networks for their enrollees as a way of providing additional options and cost savings without any diminishment of quality or patient access.  Preferred pharmacy networks represent an important tool and innovation in managed care pharmacy benefits.  The Academy supports the continued use of these programs as a beneficial way to maintain quality of care, access and cost effectiveness to the pharmacy benefit.  

Medicare Part D Quality Measures

Policy 1403

10/07/2014 Introduced

The Academy recognizes the essential role of pharmacists and plans in improving the quality of care provided to patients and supports a measure development process which allows for timely integration of evidence-based medicine and feedback from stakeholders.  AMCP additionally emphasizes the need to align measures across programs to promote consistency, economic efficiency, and quality across the health care system.

(See also AMCP Future of Medicare Part D Statement - Medicare Part D Quality Measures)