Medicare Part D plans should be required to pay pharmacists for counseling patients and dispensing oral antiviral medications that treat COVID-19, organizations representing druggists say.
Several promising COVID-19 treatments have emerged in recent weeks, led by a Merck drug that a Food and Drug Administration advisory panel recommended be approved for emergency use on Tuesday. But while the Health and Human Services Department authorized pharmacists to administer covered COVID-19 therapeutics in September, the Centers for Medicare and Medicaid Services hasn't mandated that health plans pay pharmacists for giving out the medicines.
Merck and Pfizer have developed pills to treat COVID-19 in high-risk patients. Both companies applied for emergency use authorization from the FDA. If the FDA issues emergency authorizations for these medicines while the standard approval process goes forward, the federal government will cover the cost of the medications.
But there's still no payment mechanism in place for pharmacists—who are not considered Medicare providers—to get reimbursed for evaluating patients or for filling prescriptions, said Tom Kraus, vice president of government relations for the American Society of Health-System Pharmacists.
CMS released guidance last Tuesday permitting and encouraging Part D plans to pay pharmacy claims for dispensing fees without beneficiary cost sharing, saying this could help makes these medicines more accessible. Part D plans should consider paying a higher dispensing fee than usual negotiated rates given the COVID-19 public health emergency and allowing out-of-network pharmacies to bill for the drugs, the guidance says.
There may be legal barriers to CMS taking a stronger stance on reimbursement for dispensing fees. Part D covers drugs that are approved by the FDA, and even if Merck and Pfizer's oral antivirals earn emergency authorization, full approval would be months away, at least.
Nevertheless, six pharmacy groups including the American Society of Health-System Pharmacists and the American Pharmacists Association want CMS to require that pharmacists be paid for their labor, especially since pharmacies are often the most convenient place for patients to receive healthcare services. Nearly 90% of Americans live within five miles of a pharmacist, according to the National Association of Chain Drug Stores.
"After more than a year of continuously expanding the ability of patients to access COVID-19 tests, immunizations, and therapeutics from pharmacists and other pharmacy personnel, the failure of CMS to require pharmacists to be compensated for testing, patient assessment, and ordering/prescribing, in addition to dispensing oral antivirals, makes little sense and sets up the distribution program for failure. CMS needs to clearly delineate a payment pathway necessary to allow pharmacists' patients to access these lifesaving medications," says a joint news release the pharmacist groups issued Tuesday.
Pharmacists can get reimbursed under Medicare Part B for injectable monoclonal therapies because CMS allowed them to be treated as vaccines under payment rules. But the agency can't use that workaround for the oral therapies under Part D, Kraus said.
"HHS authorized pharmacists to do the work, to do the evaluation and order the drug. But there hasn't been the corresponding solution from CMS to figure out how we pay for the services when a Medicare beneficiary needs it," Kraus said.
CMS could use its emergency authority to waive provisions of the Social Security Act and allow pharmacists to receive Medicare reimbursement for evaluating patients before giving them the pills, Kraus said. The American Society of Health-System Pharmacists, American Pharmacists Association and other organizations recommended CMS do this in a letter sent to HHS Nov. 2.
"Other payers follow Medicare, so we're concerned that if this occurs with other payers as well, then there's this question of: Can pharmacists actually realistically provide this service if there's not reimbursement for it?" Kraus said.