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Legislation Calls for Medicare Coverage of Outpatient Drugs, Pharmacists' Services

Kate Traynor

A bill recently introduced in the House of Representatives aims to provide a Medicare outpatient prescription-drug benefit that pays for pharmacists’ medication-management services.

The Medicare Drug and Service Coverage Act of 2002, also known as H.R. 3626 and the MEDS Act, would amend the Social Security Act to allow seniors enrolled in Medicare Part B and the to-be-created Part D to receive the proposed drug benefit. In its current form, the legislation includes coverage for patient education, disease-management services, laboratory-assisted monitoring of therapy, and "other professional services consistent with the scope of the practice of pharmacy."

The MEDS Act was crafted through the efforts of the Pharmacy Benefits All Coalition, a group that includes ASHP and other national pharmacy organizations. The bill was introduced in the House on January 24 by Representatives Jo Anne Emerson (R-MO) and Mike Ross (D-AR). Three cosponsors—Frank Pallone Jr. (D-NJ), Vic Snyder (D-AR), and Johnny Isakson (R-GA)—signed on in early February.

The act specifies that seniors who enroll in the new Medicare program can receive covered drugs and services at any U.S.-licensed pharmacy. Enrollees would be responsible for paying the annual deductible, after which the program covers 80% of the cost of medications and related services. Under the proposed legislation, no special financial incentives could be used to drive business toward mail-order pharmacies or other discount programs.

The pharmacy benefit would cover prescription drugs, except for "cosmetic and fertility agents," and would also pay for certain medically necessary nonprescription products. Pharmacies would be reimbursed based on the "average manufacturers’ price," an amount that reflects actual drug costs after rebates and other discounts are factored into the final price.

Pharmacy-claims processing, to be handled by private contractors, would take place through an online, real-time adjudication system. The act would require the contractors to collect substantial rebates from the manufacturers of brand-name drug products. In order to keep costs low, contracts to administer claims would be awarded through a competitive-bidding process, with reimbursement based on a fixed fee per transaction.

The MEDS Act is consistent with, but distinct from, the Medicare Pharmacist Services Coverage Act (S. 974 and H.R. 2799), which would recognize pharmacists as health care providers who are eligible to bill for drug therapy management services provided to Medicare beneficiaries.

ASHP encourages its members to educate their congressional representatives about the importance of providing Medicare beneficiaries access to pharmacists' medication management services