NOTEWORTHY...

New Pressure on Coupon Programs

Adding to mounting pressure from private payers, the GAO released a study suggesting that ASP calculations for Part B drugs include the value of coupons used in non-Medicare sales. See http://www.gao.gov/products/GAO-16-643

2016 CMS standards for Health Insurance Marketplace includes new formulary and Rx access policies

The final 2016 Notice of Benefit and Payment Parameters released by CMS establishes new standards for prescription drug coverage, formulary transparency and independent external reviews of denials of formulary exception request. CMS also clarified that cost sharing for drugs obtained through the exceptions process must count toward the annual limitation on cost sharing for health plans subject to the essential health benefit requirement. Links to resources:

Final rule: https://www.federalregister.gov/public-inspection

Annual Letter: http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2016_Letter_to_Issuers_2_20_2015.pdf

Fact sheet: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/2016-PN-Fact-Sheet-final.pdf

Payment Guide Update Published


The Academy of Managed Care Pharmacy (AMCP) has released the 2013 Update of the Guide to Pharmaceutical Payment Methods (Version 3.0) authored by Tag & Associates. The update offers a comprehensive examination of the methods and price benchmarks that have been used in the public and private sector to pay for pharmaceuticals in the United States, the changes that have occurred or are likely to occur in the future, and the forces that are behind these changes.

One of the highlights of the updated Guide is the inclusion of changes to the payment process, resulting from the Affordable Care Act. AMCP has made every effort to make the Guide an unbiased presentation of information, issues, and implications. The Guide can be found at www.amcp.org/pharmaceutical-payment-guide

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