Pharmacy Benefit Managers (PBMs) continue to make headlines, but throughout 2018, the tune has changed. What was once a frustrating topic that garnered little attention outside the pharmacy industry is now an issue that is slowly and surely being addressed, one state at a time. Between Arkansas passing legislation that regulates PBMs and Georgia’s favorable negotiations with CVS during the Aetna merger, more groups are finding creative ways to combat these industry foes.
Flaviu Simihaian, Co-Founder and Chairman of Amplicare, has been working on a solution to the obstacles pharmacies face during open enrollment. His years with Amplicare and the knowledge he has gained about independent pharmacy and Medicare have culminated in the creation of his own Medicare Advantage plan. Troy Medicare, named for the legendary city of Greek myths, is an option for independent pharmacies and their patients.
During his 7 years as CEO of Amplicare, Flaviu spoke with thousands of pharmacists and learned about all the obstacles they encountered when trying to find the most optimal Medicare plan for their patients. Sure, Amplicare could find the best option suited for the patient’s needs, but Flaviu observed that the decision was often between the lesser of two evils. The Troy Medicare team is using the insights gained from helping pharmacies with Part D enrollment to make their Medicare Advantage plan more advantageous for independents. For example, Flaviu noted that a third of Part D plan comparisons included Promethazine, a nausea medication CMS doesn’t require coverage for, forcing patients to pay the cash price. Troy Medicare will cover prescriptions like these so patients have a more affordable option.
This unique approach to Medicare coverage will be hugely beneficial to independent pharmacists, according to Flaviu. Through Troy Medicare, pharmacies will receive transparent reimbursements and NADAC pricing; DIR fees, AWP, and hidden generic MAC lists will be eliminated. Because PBMs are “so ingrained in the model,” Troy Medicare addresses the root of the problem in order to encourage more fundamental change within the healthcare system.
Currently, Troy Medicare is the only plan designed with pharmacists in mind and financially backed by pharmacy owners. “Pharmacies are trying to get paid for the clinical services they already do, and the existing plans aren’t giving a significant amount of money back to the pharmacies that are driving outcomes,” Flaviu explains. “We’re the first to really focus on pharmacy and find a way to pay them for taking care of seniors.”
This plan will initially be offered in three counties near the Charlotte, NC area in 2019. Troy Medicare has already filed its Notice of Intent and has received its contract ID number (H4676). Flaviu is optimistic that Troy Medicare will be live for the 2020 open enrollment period, but why stop in North Carolina? Pharmacy owners throughout the nation have expressed an interest in Troy Medicare, and their support is needed to ensure the plan’s momentum continues to grow. “I strongly urge other independents in other states to invest in us,” says Flaviu. “With their backing, we can prioritize the launch in their counties and continue to be independently-owned. Be a part of this from the beginning so you can affect change even faster.”
The freedom of choice is pointless if none of the options are desirable. Choosing Troy Medicare is a win for both pharmacists and their patients.