Contract Year 2021 Monitoring of Posted Comprehensive Formularies

By November 24, 2020Audits, CMS

On November 2, 2020, CMS released the results of the CY2020 Monitoring of Posted Comprehensive Formularies or their Posted versus Approved (PvA) analysis.  For the CY2020 analysis, CMS announced that 3 of the 175 Part D contracts (1.71%) showed a discrepancy between the CMS formulary and what was posted on the plan’s website.  CMS noted these discrepancies included the failure to included covered drugs, incorrect representation of the drug’s utilization management requirements, and tiers that were not consistent with the plan’s benefit.

CMS will continue to perform this analysis for CY2021.  CMS noted that plans included in the analysis will included randomly selected plans, new sponsors, and any sponsors with previously identified posted formulary issues.  CMS will notify any plans selected for the analysis as well as providing a workbook containing any discrepancies following the completion of the analysis.

It is highly recommended for plans to perform their own analysis to ensure the January 1st plan formulary is consistent with the CMS formulary.  Plans should carefully review drug availability, formulary tier, and any utilization management edits including step therapy, prior authorization, and any quantity limits.  New drugs and any drugs with any year-over-year changes should be targeted as these changes would cause a change to the previous formulary document.  BluePeak has completed several mock CMS audits in the past and can assist with validating the accuracy of the posted formulary.