Your members save with $4 generics–but do they cost your Medicare Advantage plan?

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RxLink can improve your adherence metrics as measured by the Medicare Star Rating System
while saving money for you and your members

Medicare Advantage plans receive millions of dollars in bonuses from the Federal Government when they show better outcomes based on metrics calculated by CMS (Centers for Medicare and Medicaid Services).

One of these metrics is the Medicare Star Rating System, which reports on medication adherence. While the methodology itself has some issues, chiefly the fact that it equates Rx fills with actual adherence and outcomes, it’s still a key metric used to reward health plans that drive better adherence.

What if your covered patients are adherent but CMS doesn’t know?

Many leading pharmacy providers, particularly Walmart and those within grocery chains such as Kroger, offer low-cost generics. Pricing is usually $4 for a 30 day supply or $10 for a 90 day supply. Typical low cost generics available at these prices include widely prescribed drugs like atorvastatin (Lipitor,) clopidogrel (Plavix) and fluoxetine (Prozac.)

These prices often make the cash price cheaper than using a Medicare Advantage insurance plan for the same prescription. Your members save money. Their prescription plan doesn’t have to process a claim. What’s the downside?

CMS calculates adherence based entirely on claims data,
they will never see that these patients are compliant!

This means that a patient who fills once with a claim and then refills using cash looks like they have become noncompliant, while they may be continuing to fill and use their prescribed medications. Patients who always fill with cash could, in an aggregate CMS analysis, look like they are not receiving proper therapy for chronic conditions such as hypertension or hyperlipidemia. 

RxLink can provide visibility into prescription fills…and savings for your members

RxLink offers comprehensive discounts on prescription drugs to your patients, usually comparable to or less than a $4 generic program. We compare pharmaceutical discount offers across our network, inform patients of manufacturer offers where applicable, and provide a single lowest-cost recommendation that accounts for your plan structure and co-pay.

When a discount card will be cheaper for your members, and for you as their health plan, we can recommend it to your members. In addition to these cost savings we can provide you with comprehensive reporting to show CMS that your members taking advantage of savings are still compliant with their medications.

If you are a payer or employer, RxLink can help you rethink your approach to supplying pharmacy benefits while maintaining or improving your Medicare Star Rating for medication adherence.

E-mail us at info@rxlink.com to start the discussion!