CMS Releases Draft Call Letter for Medicare Advantage and Part D Drug Plans

APhA will submit comments by March 3

On February 1, CMS issued its annual draft call letter, which Medicare Advantage prescription drug plans (MA-PDs) under Part C and prescription drug plans (PDPs) under Part D will use to craft their bids 2018. CMS will finalize the call letter in April and plan bids are due in June.

The call letter sets benefit parameters for the defined standard benefit received by plan beneficiaries. It also includes a number of provisions of interest to pharmacists including: proposed changes to the plan star ratings; display measures; existing, new, and future plan requirements, including point-of-sale (POS) edits and pharmacist overrides to prospectively prevent opioid overutilization; specialty tier pricing; and access to preferred cost sharing pharmacies (PCSP). APhA will submit comments before the March 3 deadline.

Standard benefit changes

Standard Benefit


2018 (Proposed)




Initial coverage Limit



Individual out-of-pocket threshold



Minimum cost-sharing for generic/preferred multisource drug



Minimum cost-sharing for other drugs




The donut hole

The coinsurance in the coverage gap or “donut hole” associated with the Part D benefit continues to shrink. It will be eliminated by 2020.


2018 (proposed)

Beneficiary coinsurance

Plan liability

Applicable medications (brand)

35% (from 40%)

15% (from 10%)

Non-applicable medications (generic)

44% (from 51%)

56% (from 49%)



Beneficiaries will be responsible for the costs associated with immunizations at the coinsurance rate specified with their plans. For 2018, the beneficiary will pay 35% and plans will pay 65% of dispensing fees and administration fees while in the coverage gap.

Plan star ratings

CMS publishes the Part C and D star ratings each year to measure both the quality of and reflect the experiences of beneficiaries in MA, MA-PDs, and PDPs to help beneficiaries select the best plan for them, and determine MA quality bonus payments.

New measure

Medication reconciliation postdischarge (Part C): CMS adds this measure to determine plans’ star ratings. It measures the percentage of beneficiaries discharged from acute or non-acute inpatient facilities whose medications were reconciled within 30 days of discharge. CMS is considering adding medication reconciliation postdischarge to a broader set of future measures related to care transitions.

Changes to existing star rating measures

Improvement measures (Part C & D): CMS will continue basing the improvement measure on metrics with at least 2 years of data. Measures that count toward the overall improvement measure that could reflect pharmacist participation include:

Part C:

  • Care coordination—patients’ experience and complaints measure

Part D:

  • Getting needed prescription drugs—patients’ experience and complaints measure)
  • Medication adherence for diabetes medications—intermediate outcome measure)
  • Medication adherence for hypertension—intermediate outcome measure
  • Medication adherence for cholesterol (statins)—intermediate outcome measure
  • Medication therapy management (MTM) program completion rate for comprehensive medication review (CMR)—process measure


Measures removed from star ratings

High-risk medication (HRM) use (Part D): the measure is transitioning to a display measure for 2018. The decision is based upon statements from the Pharmacy Quality Alliance (PQA) and the American Geriatrics Society, which highlighted that the intent of the measure was not to be punitive, as medications on the HRM list are not contraindications and are only recommendations and considerations. The revised PQA HRM drug list excludes three drugs (thioridazine, trimethobenzamide, and chloral hydrate), and adds 14 new HRM drugs. It will be reconsidered for the star ratings once PQA completes any analyses and specification changes.

2018 display measures

The “display measures” are not included in the plan ratings, but are used to facilitate quality improvement by the plans. All 2017 display measures will remain display measures for 2018, but some of the measures contain specification changes, including the following revised and new measures.

Part C:

  • Pneumococcal vaccination status for older adults: currently collected through patient surveys, CMS is exploring better ways (e.g., claims, case management systems, medical records, registries, and electronic health records) to assess immunization status.
  • Statin therapy for patients with cardiovascular disease: measures the percentage of males 21–75 years of age and females 40–75 years of age who were identified as having clinical atherosclerotic cardiovascular disease and received at least one high- or moderate-intensity statin medication during the measurement year. CMS plans to include this measure in the 2019 star ratings.

Part D:

  • High-risk medication use: see above.
  • Drug-drug interactions: measures the percentage of Medicare Part D beneficiaries who received a prescription for a target medication and received a prescription for a contraindicated medication with or subsequent to the initial prescription during the measurement period. PQA updated the list of medication pairs associated with this measure and CMS is planning use 2017 data to implement the revised drug list for the 2019 display measures.
  • Antipsychotic use in persons with dementia (APD): replaces the “chronic use of atypical antipsychotics by elderly beneficiaries in nursing homes” measure. Measures the percentage of Medicare Part D beneficiaries 65 years or older with dementia who received prescription fills for antipsychotics without evidence of a psychotic disorder or related condition. CMS proposes to add only the overall APD measure to the 2018 display page (using 2016 data). CMS proposes to also report two population breakouts—community-only (never a nursing home resident) and long-term nursing home residents (more than 100 days in a nursing home)—for the 2019 display measures (using 2017 data). CMS will assess adding the APD measure to the star ratings in the future.
  • Use of opioids from multiple providers and/or at high dosage in persons without cancer: The measures examine multiprovider and/or high-dosage opioid use among individuals 18 years and older without cancer and not in hospice care. PQA updated the measures. CMS proposes to add the measures to the 2019 display page (using 2017 data). Changes include:
  • The treatment period for opioids at high doses (OHD) and opioids at high doses from multiple providers (OHDMP) must be 90 days or more.
  • The morphine equivalent dose (MED) is changed to morphine milligram equivalents.
  • ICD-9 and ICD-10 codes will be changed to align with the American Medical Association Physician Consortium for Performance Improvement cancer value set.
  • All buprenorphine products indicated for medication-assisted treatment (MAT) will be excluded.
  • Statin use in persons with diabetes: measures the percentage of patients between 40–75 years old who received at least two diabetes medication fills and also received a statin medication during the measurement period, excluding end-stage renal disease and hospice patients. The measure is planned to become a star rating measure for 2019.


Measures for 2019 and beyond

Part C:

  • Care coordination measures: CMS believes one of the most important aspects for MA organizations is to help better manage care transitions and coordinate care. As a result, CMS is planning to categorize all care coordination measures starting with the 2019 star ratings. CMS has recently awarded contracts to help identify new care coordination measures.
  • Telehealth and remote access technologies: CMS welcomes feedback on the appropriateness of including telehealth and/or remote access technology encounters—including behavioral health—as allowed under the current statutory definition of Medicare-covered telehealth services and/or as a provided by the MA plan as a MA supplemental benefit, as eligible encounters in various Part C quality measures.
  • Transitions of care: CMS is currently collecting comments on the newly endorsed transitions of care measure that has four different indicators associated with it (see below). The measure would be potentially collected in calendar year 2018 for use on the display page in 2020.
  • Notification of inpatient admission.
  • Receipt of discharge information.
  • Patient engagement after inpatient discharge
  • Medication reconciliation post-discharge
  • Opioid overuse: instead of the PQA measure assessing the percentage of members receiving opioids from multiple providers—including four or more prescribers and four or more pharmacies—the new measures would report a rate for the percentage of members receiving prescriptions for opioids from four or more prescribers, and a separate rate for the percentage of members receiving prescriptions for opioids from four or more pharmacies. Once testing is complete, CMS is looking to include for the 2020 display measures based upon 2018 data.

Part D:

  • Improving drug utilization review controls in Medicare: in July 2013, CMS launched the Overutilization Monitoring System (OMS) to help oversee sponsors’ compliance. CMS is soliciting comments about new proposals to reduce the unsafe overutilization of medications by Part D beneficiaries, including:
  • Changes to the retrospective OMS opioid overutilization methodology (shorten the measurement period from 12 months to 6 months for use of opioids with an average daily MED exceeding 90mg for any duration; and received opioids from more than three prescribers and more than three pharmacies, or from more than four prescribers regardless of the number of opioid dispensing pharmacies, excluding cancer diagnoses and hospice beneficiaries.
  • Additional guidance about prospective formulary-level cumulative POS edits: CMS expects all plans to implement a hard edit at a minimum in 2018, using reasonable controls to limit false positives. Plans may also choose to continue to implement soft edits in 2018. CMS is soliciting feedback from plans on their experience with these edits to date, including pharmacist overrides/responses, if available, and setting the threshold at or above 200 mg MED.
  • Improving drug utilization review controls in Medicare: in July 2013, CMS launched the Overutilization Monitoring System (OMS) to help oversee sponsors’ compliance. CMS is soliciting comments about new proposals
  • Addressing chronic use of benzodiazepine sedative-hypnotics (BSH) in the Medicare Part D population: CMS recognizes monitoring before this becomes chronic.
  • Concurrent use of opioids and benzodiazepines (in development): would measure the percentage of individuals 18 years and older with concurrent use of opioids and benzodiazepines.

CMS’s policy goals are to improve the identification of inappropriate opioid use (i.e., reduce “false positives” related to overutilization that resolved recently and to better identify the most egregious cases of overuse); align with the CDC guideline on opioid prescribing, if applicable; and define a target population for which the caseload would be manageable for Part D plans.

Clarification of Part D “reference-based pricing” policy

CMS clarified that the prohibition on “reference-based pricing” only applies to the cost-sharing designs that require enrollees to pay a differential (i.e., penalty) based upon the difference between the negotiated price of the drug being dispensed and a lower-cost preferred reference drug. The policy does not otherwise prohibit reference-based payment arrangements negotiated between pharmacies and Part D sponsors (or their PBMs) that establish the negotiated price.


Annual MTM eligibility cost threshold: in 2017, MTM-eligible beneficiaries have multiple chronic diseases, take more than one Part D drug, and are likely to incur costs that meet or exceed the $3,919 threshold (up $412 from the previous year). CMS will adjust the threshold for the 2018 program in the final call letter. Pharmacists support CMS revisiting the cost threshold for CY 2018, as the current threshold excludes many beneficiaries with complex conditions but smaller drug spends but who could benefit from MTM services.

Enhanced MTM model: the enhanced MTM model that allows pharmacists to provide additional health care services to beneficiaries began on January 1. Some stakeholders expressed concern that the enhanced MTM model test may adversely influence the star ratings of contracts ineligible to participate. Part D sponsors with plans participating in this model must establish MTM programs in compliance with current requirements and reporting data for the remaining plans under each Part D contract. Therefore, the MTM program CMR completion rates will be calculated using available plan-reported data from the remaining plans under the Part D contract. CMS plans to analyze if this approach significantly advantages or disadvantages enhanced MTM model participants and evaluate potential adjustments as necessary.

Specialty-tier pricing

CMS will maintain the $670 specialty-tier cost threshold for CY 2018. Pharmacists should watch for drugs at this cost threshold and inform patients that these prescriptions may take a few additional days to be filled at a specialty pharmacy and that they should anticipate prior authorization requirements.


Plans that have the following minimum access standards to PCSPs will be identified as outliers in 2018 and succeeding years, unless CMS notifies sponsors of a change in the thresholds in a future call letter. Outlier plans will be required to disclose in marketing materials, including websites, that their plans’ PCSP networks offer lower access.


Pharmacy access within 2 miles of less than 40% of beneficiaries’ residences


Pharmacy access within 5 miles of less than 87% of beneficiaries’ residences


Pharmacy access within 15 miles of less than 70% of beneficiaries’ residences