Running potenitally high risk meds through for cash instead of the patient's part D plan?

[justjoe]

We get penalized by Medicare if we run through meds like amitriptyline and cyclobenzaprine through for Medicare Part D patients. Is it lawful to run them through for cash? What if the doctor still wants the medication and we document it?

---

Members don't see this ad.

 

[txpharmguy]

We get penalized by Medicare if we run through meds like amitriptyline and cyclobenzaprine through for Medicare Part D patients. Is it lawful to run them through for cash? What if the doctor still wants the medication and we document it?

As long as it's a valid prescription, you can fill it cash. Is it a first time fill or has pt been on it previously? I'd just discuss and document fall risk, etc and fill.

 

[Leper Messiah]

wait, this is a new concept to me. Medicare will penalize the pharmacy even after the physician has been consulted? What type of penalty are we talking about?

 

[Ackj]

wait, this is a new concept to me. Medicare will penalize the pharmacy even after the physician has been consulted? What type of penalty are we talking about?

I believe it's something to do with star ratings. I do not think it's directly a penalty in the sense that you'd have to pay a fine for it.

The bigger question, in my mind, if Medicare really doesn't want it filled, why are they accepting the claim? Why not make it like cough syrups and put them all as "not covered by plan" ?

 

[PharFromNormal]

Some PBMs/sponsors may include hrm performance in their DIR calculation as a trickle down from STARs. However, HRM is currently not a weighted STAR measure but that may or may not change in future years where the rating is actually based off this year. In terms of unlawful, I think it's unlawful to switch the patient without informing them. If they want it filled through their benefit and you are cashing it out (especially if the patient is now paying more OOP) and they are not aware and they do not approve, you might be putting yourself at a contractual risk.

 

[ldiot]

Wait why do you get penalized in the first place for filling a high risk med? Also since we are talking about part D I assume this is outpatient... I thought most outpatient pharmacies weren't even ranked yet by medicare star ratings?

 

[PharFromNormal]

Wait why do you get penalized in the first place for filling a high risk med? Also since we are talking about part D I assume this is outpatient... I thought most outpatient pharmacies weren't even ranked yet by medicare star ratings?

Pharmacies aren't ranked by CMS. CMS gives Medicare plans their STAR ratings. The Medicare plans then turn around and create performance networks (via their pbm) largely leveraging the DIR mechanism to incentivize/penalize performance on any metrics they want. They usually are largely based off pharmacy related STAR measures (adherence) to align incentives to what the plan wants at the end of the day to look good in the eyes of CMS. They can include other things like 90 day mix, generic dispensing rate, others... all depends on the confidential network terms between the pbm and the pharmacy.

 

[BidingMyTime]

I think that is ridiculous. Amitriptyline & cyclobenzaprine are not "high-risk" meds in the way that say warfarin or clozapine are high-risk meds. Yes, there are more potential problems in with amitriptyline & cyclobenzaprine in the elderly, but that is something for the doctor to determine on a case by case basis, if the benefits of these drugs outweigh potential risks.

 

[npage148]

I'm pretty sure the inclusion of benzods and z-drugs are just a way to troll everyone. You trying telling an old folk you want to take their ambien away.

 

[Ackj]

I'm pretty sure the inclusion of benzods and z-drugs are just a way to troll everyone. You trying telling an old folk you want to take their ambien away.

Most folks here can get only #30/180 days, then pay cash rest of the time.

 

[Wickett]

wait, this is a new concept to me. Medicare will penalize the pharmacy even after the physician has been consulted? What type of penalty are we talking about?

My company has its stores graded by equipp on a 5 star system (grades how many elderly on high risk meds, how many diabetics on statins, fill compliance rate for RAS meds, etc). The lower our score, the lower our reimbursement for Medicare. If we don't hit the 5 star metric on a certain thing, we get 0 points for that score.

It also a big chunk of the score corporate gives each location, determining bonuses and such. It's a huge pain in the ass, because you get penalized even if you document MD won't change a high risk med, refuses to put on a statin for a diabetic (one doc at my location tanks our score because he rarely adds on statins and told us to stop faxing about it), or if patients don't listen to you about regularly filling their maintenance meds.

I'm all for incorporating these metrics, but pharmacies shouldn't be penalized if you document an MD or patient refuses to follow your recommendation, imo.

 

[ldiot]

If the diabetic patient isn't on a statin why don't they penalize the doctor instead of the pharmacy who doesn't even have access to their medical chart? They just want us to spend all day on the phone instead of doing it themselves?

 

[npage148]

If the diabetic patient isn't on a statin why don't they penalize the doctor instead of the pharmacy who doesn't even have access to their medical chart? They just want us to spend all day on the phone instead of doing it themselves?

Or I get this response "their cholesterol is fine, they don't need a statin" I'd fax over the whole guidelines with notations but it's a small town and id alienate the practice which is sees 1/2 the town

 

[ldiot]

Or I get this response "their cholesterol is fine, they don't need a statin" I'd fax over the whole guidelines with notations but it's a small town and id alienate the practice which is sees 1/2 the town

We haven't talked about diabetes yet so I can't really make an intelligent argument but if I'm not mistaken the guideline itself isn't even universally accepted in terms of initiating aspirin/statins. And since I'm on the topic I think they changed the monitoring parameters for statins such that the LDL is no longer the measure of efficacy anyways but rather it is the "amount of statin in the body", which I presume relates to adherence and time in therapeutic window. Again this is something that was just mentioned in passing in school, we haven't done diabetes yet.

 

[Chodronfan]

We usually call and see if they will consider baclofen instead of cyclobenzaprine I think that is ok with Med D but I am not sure if it is less of a fall risk-I've never taken it. I am not sure of the suitable Med D switch for amitriptyline. And getting the elderly to give up their benzos?! Oh boy only out of their cold dead hands. Maybe someone could invent a combination benzodiazepine-statin. I would get dinged for having the elderly on a benzo but snaps for having them on a statin. And patients would be suuuupppper compliant.