Participation is expected to be strong in the Part D Senior Savings Model launch on 1/1/21 with 1,750 plans across 88 sponsors and 3 manufacturers participating in the program. Participating Plans will be offering a broad set of plan-formulary insulins at no more than $35 copay through all stages of the benefit. Given that this is a new program that has been highly publicized, participating Plans will want to ensure rigorous oversight of this program. Here are some operational review items that plans should pay particular attention to before and during the implementation of the model in 2021.
- Claims/Formulary Testing
- Insulin claims should be reviewed for accurate pricing at all stages of the Part D benefit. This means ongoing testing and monitoring on January 1st and throughout the plan year. In addition, if preferred pricing is being offered at certain pharmacies or pharmacy networks, those prices should also be validated.
- Plans should validate beneficiaries are being charged the designed plan copay and no more than a $35 copay for a one-month supply of the applicable product. Cost-sharing should be applied during all phases of the Part D benefit excluding the catastrophic benefit phase.
- The gap discount logic on these products would need to be updated to apply the gap discount on the ingredient cost and sales tax within the coverage gap. Plans should thoroughly review test claims to validate straddle claims and any claims with fees are processing appropriately.
- If the plan has a deductible that applies to all drugs or just to branded medications, plans should validate the deductible is not being applied on the applicable products.
- It is highly recommended plans incorporate the appliable insulin products into their monitoring and oversight processes throughout the 2021 plan year. Monitoring should be implemented within the first week of the plan year to validate the program is working as intended to prevent potential disruption to the beneficiary population.
- Plans should review their printed and online formularies to ensure that the correct insulins have the SI (select Insulin) designator properly assigned.
- PDE
- The PDE logic within the coverage gap would need to be updated on these applicable products to report the amount outside the defined standard benefit in the Patient Liability Reduction due to Other Payer (PLRO) and not under the Part D enhanced or Non-Covered Plan Paid (NPP) field.
- Plans should prioritize reviewing the first 2021 PDE response files to determine if CMS is rejecting any PDE records for these products. The plan should perform a root cause analysis and adjust any logic as needed to mitigate any additional beneficiary impact.
- Call Center Training
- It will be important for call center representatives (CSRs) to be fully versed in the program. Training should be provided to CSRs to ensure they provide accurate cost estimates on participating and non-participating insulins. CSRs should also be prepared to explain why certain insulins are included based on manufacturer implementation.
