CMS Backs Up CVS Network Exclusions Under Part D

Tony Hagen @oncobiz
Published: Tuesday, Sep 20, 2016
There is a need for physicians to have in-house control over Part D oral distribution, Cox argues. The mere fact that Part D drugs are oral doesn’t make them easier to manage, or less toxic, he said. “It doesn’t reduce the number of side effects. In fact, it sometimes complicates things because it makes medication adherence infinitely more difficult. It requires a high level of coordination of care and real-time access to the latest patient medical records—so that we can manage patients in a very timely fashion, make rapid dosing adjustments when necessary, and dispense smaller quantities to patients that are having frequent dosage adjustments. This then leads to reduced waste and significant reductions in cost.”


Table: Economics of Specialty Drug Spending

Table: Economics of Specialty Drug Spending

Source: Frier Levitt

CVS is one of the big five pharmacy benefit managers that control virtually all Part D payments, according to COA. Those five also include Express Scripts, Prime Therapeutics, and OptumRx, according to a white paper commissioned by COA and authored by Frier Levitt. The move by CVS to place in-house physician dispensaries out-of-network for purposes of Medicare Part D drug payment would force hundreds of thousands of cancer patients across the country to find alternate sources for their oral oncolytic drugs, according to the paper.

Cox’s Dayton practice has considered becoming a licensed pharmacy so that it could continue to participate under the CVS Caremark program. This would involve hiring a licensed, full-time pharmacist, Cox says, and it would enable the practice to continue dispensing under CVS’s sponsorship status. However, it would not affect the practice’s ability to increase dispensing under other coverage plans. “All of those restrictions would still be in place.” And whereas hiring a pharmacist is a possibility for the Dayton group, smaller practices likely would not be able to afford to do so, Cox says.

“We have built our dispensing programs in our office for patient convenience and to be able to impact medication adherence and clinical outcomes, and it’s unfortunate, to say the least, when we are powerless to affect change in that regard—when an outside entity takes away the freedom of choice for our patients and then renders us powerless or, at the least, puts us in a situation where we’re handicapped in our ability to provide comprehensive care for our patients,” Cox states.

Huge consolidation among pharmacy benefit managers has given the remaining players enormous control over the healthcare market. The influence of these companies is further leveraged by the subsidiary pharmacy benefit plans and pharmacy retail outlets they own.

For the oncology care market, the oncolytics that fall under the Medicare Part D benefit represent a rapidly growing slice of activity at in-house pharmacies. “In 2015, 37% of the total US spending on drugs was attributed to specialty medications, and specialty medications are projected to account for 50% of total drug spend by 2018,” the white paper said. “By 2020, specialty drug spend is projected to total about $400 billion, representing about 9% of national health spending. Moreover, dispensing physicians comprise about 46% of the specialty medical spend.”



Frier Levitt, LLC. Pharmacy benefit managers’ attack on physician dispensing and impact on patient care: case study of CVS Caremark’s efforts to restrict access to cancer care. Published August 2016. Accessed September 1, 2016.

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