Government Shutdown Unlikely After Boehner Announces Retirement: House Speaker John Boehner (R-Ohio), faced with a constant conservative rebellion, announced Friday he will retire at the end of October, ending a turbulent five-year tenure atop the House of Representatives. Boehner’s nearly five-year hold on the speaker’s gavel had grown increasingly unsteady amid threats from more than 30 Republicans that they would force a no-confidence vote in his speaker’s position.
The surprising move means there’s unlikely to be a government shutdown. Following Boehner’s announcement, House Republicans said there was agreement to pass a clean spending bill to keep the government open. Several members of the Freedom Caucus, the conservative group which led the revolt against Boehner’s leadership, said they will now support the spending bill without demands that it include language to cut off funding for Planned Parenthood.
Boehner's decision will set off a leadership scramble. Second in line is House Majority Leader Kevin McCarthy (R-Calif.), who is widely expected to serve as the next speaker. But there is serious unrest in the House Republican ranks, as a small group of conservatives have continuously clashed with more establishment Republican types and McCarthy would need to take 218 votes on the House floor to win. Should McCarthy win, it will set off an intense battle for majority leader. House Majority Whip Steve Scalise (R-La.) has been laying the groundwork for that battle, as has House Republican Conference Chairman Cathy McMorris Rodgers (R-Wash.). Chief Deputy Whip Patrick McHenry (R-N.C.) will be favored for House Republican whip.
Reminder: TRICARE Brand Name Rx Changes Coming Oct. 1: All TRICARE beneficiaries, except active duty service members, must get select brand name maintenance drugs through either TRICARE mail order or from a military pharmacy beginning Oct. 1 or pay the full cost at a retail pharmacy. TRICARE patients can continue to receive all generic drugs as well as drugs for shorter-term needs at their community pharmacy with no co-pay changes. This is an extension of the current TRICARE for Life pilot program that started in March 2014. Patients may be granted a waiver to continue to receive all their medications at their community pharmacy in limited scenarios such as an emergency, personal needs or special circumstances such as residing in a nursing home. Have patients or their caregivers call Express Scripts at 1-877-363-1303 to request a waiver.
To help clarify confusing information that patients may have received about the program, NCPA has prepared a one-page letter outlining some of the changes for distribution to TRICARE patients. A list of the select brand name maintenance drugs impacted can be found here: http://www.health.mil/selectdruglist.
NCPA members recently alerted us that TRICARE beneficiaries are receiving the confusing letters from TRICARE which say, "If you continue to get select maintenance drugs at a network pharmacy, you'll pay 100% of the cost." NCPA has contacted TRICARE leadership about this extremely misleading letter, asking for clarification.
CMS Releases Medicare Advantage and Part D “Landscape Files”: Medicare Advantage enrollment is expected to keep rising in 2016 while premiums will be slightly less. Despite $200 billion in cuts that were made to the program under the Affordable Care Act, average premiums will drop from $32.91 per month in 2015 to $32.60 in 2016. The landscape files show information on which plans will serve each county and what premiums will be. Open enrollment will take place between Oct. 15 and Dec. 7, and plans may begin marketing Oct. 1.CMS offers a release about each state, indicating the number of MA and stand-alone prescription drug plans available, and the lowest monthly premium available for a prescription drug plan, among other data. NCPA’s initial analysis of the files includes the following:
The 2016 landscape (as far as National Plans go) looks much like the current 2015 field. There are a few less enhanced plans as plan sponsors have been forced to merge some of their offerings as a result of mergers/acquisitions (Aetna dropped its enhanced plan and is using the First Health plans as its enhanced offerings. Cigna-Healthspring also dropped one of its enhanced plans, potentially because it wasn't significantly different from its other enhanced plan).
Humana Walmart continues to have a low, nationwide premium ($18.40), but a few PDPs have found a way to offer an even lower premium in a few of the 34 regions (Aetna Saver has $14.50 in 1 state, Wellcare Classic has $18.20 in 1 state and $18.40 in 1 state, SilverScript Choice has $11.40 and $12 in 1 state, respectively). But nothing substantial to challenge the Humana Walmart low nationwide premium.
Torchmark's United American plans are under sanction and can't participate in enrollment season.
NCPA Urges Senators to Examine Consolidation, Impact of PBM Corporations: This week the Senate Judiciary Committee Subcommittee on Antitrust, Competition Policy and Consumer Rights held a hearing to look into significant consolidation among health insurance companies. NCPA took the opportunity to reiterate it is also an appropriate time to examine the effects of consolidation in the pharmacy benefit management (PBM) corporation industry. A recent House subcommittee hearing broached these issues. Expert witnesses expressed to Congress their concern that PBM corporation consolidation may limit competition and may be ripe for review by regulators such as the Federal Trade Commission. NCPA will continue to closely monitor the rampant consolidation in the marketplace and to fight for patient choice and access and the vital role of independent community pharmacists to health care.
ICD-10 Implementation Begins October 1st: Oct. 1 is the compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10, the Department of Health and Human Services has announced. ICD-10 is the10th revision of the International Classification of Diseases, which provides the medical data code sets for coding diagnoses (ICD-10-CM). Below are some key take-aways for pharmacies to be aware of to ensure compliance:
- Diagnosis codes in the current ICD version are always required on prescriptions for Medicare Part B claims for proper adjudication. Some prior authorization claims will also require submission of a diagnosis code, along with claims for Workers Compensation.
- Beginning Oct. 1, ICD-10 will be the required version for documenting diagnosis codes—claims that are submitted in ICD-9 or other prior versions will be rejected.
- For electronic prescriptions—if the resulting claim requires a diagnosis code and would have been required on a paper prescriptions, an ICD-10-CM code would need to be submitted on the electronic prescription as well.
- Pharmacies are advised to work with their trading partners, system vendors, and any other billing intermediaries to prepare for the change to ICD-10. Resources such as crosswalks and mapping may assist entities in converting from ICD-9 to ICD-10 when there is an exact match. However, in instances where there is not a corresponding code, pharmacies are strongly encouraged to proactively reach out to physicians to obtain the new ICD-10 codes to allow pharmacy systems to store these codes that will be needed for claims submission by the compliance date.
- To better prepare for these changes, it is also recommended that pharmacies generate reports on patients with active Medicare Part B claims to anticipate which prescriptions will require the updated diagnosis codes.
- Patients should be alerted that there may be a delay in care as pharmacies need to contact their prescriber for updated information before they are able to fill certain prescriptions, due to a change in Medicare rules.
For more information, please visit the Provider Resource page on ICD-10 provided by the Centers for Medicare & Medicaid Services or review this document from NCPDP with a 'Frequently Asked Questions' section for pharmacies.
EPA Releases Proposed Rule on Hazardous Waste Management: the Environmental Protection Agency released a long awaited proposed rule governing the management of hazardous pharmaceuticals. Certain pharmaceuticals are regulated as hazardous waste under the Resource Conservation and Recovery Act (RCRA) when they are discarded. Healthcare and other associated facilities that generate hazardous waste pharmaceuticals have reported difficulties complying with hazardous waste regulations due to several factors. EPA has acknowledged that healthcare workers, whose primary focus is to provide care for patients, are often not knowledgeable about the RCRA hazardous waste regulations, but find themselves involved in the implementation of such regulations. Second, a healthcare facility can have thousands of items in its formulary, making it difficult to determine which ones are hazardous wastes when disposed. Third, some active pharmaceutical ingredients are listed as acute hazardous wastes, which are regulated in small amounts.
To facilitate compliance and to respond to these concerns, EPA is proposing to revise the regulations to improve the management and disposal of hazardous waste pharmaceuticals and tailor them to address the specific issues that hospitals, pharmacies and other healthcare-related facilities face. The revisions are also intended to clarify the regulation of the reverse distribution mechanism used by healthcare facilities for the management of unused and/or expired pharmaceuticals. NCPA is reviewing the proposed rule and will provide comments on behalf of our members from both a community pharmacy as well as long term care perspective.
USP Proposes Revisions to General Chapter <797>: USP pre-posted proposed revisions to General Chapter <797> Pharmaceutical Compounding – Sterile Preparations for public comment at www.usp.org/usp-nf/notices/general-chapter-797-proposed-revision. The chapter, which has been under review by the Compounding Expert Committee since 2010, has been significantly revised to clarify requirements, reflect feedback from stakeholders, and incorporate new learnings. USP encourages impacted stakeholders to review the chapter and submit comments on its content.
Major revisions of the General Chapter include:
- Reorganization of existing sections and placement of procedural information in boxes
- Collapsing of the three compounded sterile preparation (CSP) microbial risk categories (e.g. low-, medium-, and high-risk) into two categories (Category 1 and 2) distinguished primarily by the conditions under which they are made and the time within which they are used.
- Removal of information on handling hazardous drugs and added cross-references to <800> Hazardous Drugs—Handling in Healthcare Settings
- Introduction of the terminology “in-use time” to refer to the time before which a conventionally manufactured product used to make a CSP must be used after it has been opened or punctured, or a CSP must be used after it has been opened or punctured.
NCPA will review and submit comments accordingly by the January 31, 2016, deadline.