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| Hello Friends
This year marks the 20th anniversary of the implementation of the Medicare Modernization Act. Those of you who were around back then probably remember the chaos that began in January as we quickly learned how unaccustomed PBMs were to the LTC environment.
Mountains of unpaid claims quickly appeared and we had weekly conference calls with CMS to untangle the mess that never seemed to resolve. Over the first several months a rhythm began to evolve, where industry pros explained the problems, CMS then discussed the problems with PBMs and resolutions began to be seen.
The heroes of this period in LTC Pharmacy history were the dozens of pharmacy professionals who patiently informed CMS of life on the ground, and the consistent efforts of CMS to get issues resolved. We owe a great debt of gratitude to the late Dr. Jeffrey Kelman who was medical director at CMS who always showed up and followed up.
So, 20 years later and here we are. Different challenges but the same legacy. Things get better when we work together.
Paul |
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| | | | Bipartisan Bill Introduced to Force PBMs to Divest Pharmacies
This legislation was initially introduced in 2024 and is now being reintroduced following state action in Arkansas and Tennessee to ban PBMs from owning pharmacies. The Patients Before Profits Act was introduced in the Senate by Sen. Warren (D-MA) and House bill was introduced by Rep. Harshbarger (R-TN).
Bill Text
CMS Issues FAQs on Billing for Medication Deprescribing
The Medicare Physician Fee Schedule offers opportunities for physicians (and pharmacists) to bill for activities involving the reduction of dose or the removal of specific medications from a patient's drug regimen. This FAQ offers instances where this can be done and billing codes that would apply. See Document
CMS Considering Auto-enrolling Medicare Beneficiaries in MA Plans
Under current practice, new Medicare beneficiaries who do not choose a plan are auto-enrolled in traditional Medicare. However, the Trump Administration is reportedly considering opening auto-enrollment to include enrollment in Accountable Care Organizations, and Medicare Advantage plans. More
CMS Freezes Home Health and Hospice Medicare Enrollment
CMS announced that, effective immediately, Medicare would freeze enrollment of new Home Health and Hospice providers. Citing 'deep and systemic fraud', CMS Administrator Dr. Mehmet Oz announced that CMS would aggressively investigate and remove providers who are committing fraud. More
CMS to Provide Access to GLP-1 Drugs in Medicare
CMS announced that this summer Medicare beneficiaries will have access to GLP-1 drugs for weight loss under certain circumstances. Participating beneficiaries will be charged $50 per month and will available to beneficiaries covered under Part D (PDP plans) or Part C (Managed Medicare) and some other arrangements. More
Plan Details
CMS News Release
Administration for Community Living Announces Health at Home Challenge
The agency announced an effort to smooth access to care for dually-eligible individuals through coordinated care programs. The emphasis is on putting community-based organizations to work with healthcare providers to identify and eliminate barriers to care in selected communities. Looks like an opportunity for pharmacy. More |
| | | | Virginia Supreme Court Voids Redistricting
In the ongoing battle to shape the battlefield for the mid-term federal elections, a voter-approved plan to reshape Congressional districts in Virginia was voided by the state's highest court. The change could have the Democrats the opportunity to increase their majority of House delegations from 6-5, to 10-1. The court ruled that the legislature didn't approve the measure until voting had already begun. More
Why Pharmacy Provisions in the Inflation Protection Act Hurt Pharmacies
Industry officials and trade groups have sounded the alarm about the damage that will be done to LTC Pharmacies (and retail pharmacies) because of provisions of this landmark law. The Journal of Managed Care Pharmacy published an informative paper that quantifies these problems and explains the threat. More
United Healthcare to Cut Prior Authorization by 30 Percent
The giant health insurer announced that, by the end of the year, it would eliminate 30 percent of prior authorization requirements for such services as diagnostic procedures. More
CVS Q1 Financials Beat Analyst Estimates
Omnicare parent CVS Health reported Q1 revenue and earnings, beating analyst estimates on both counts, with revenue up from $94.6 billion in Q1 2025 to $100.4 for Q1 2026, and profits rising from $1.8 billion in Q1 in 2025 to $2.9 billion in Q1 2026. More
CVS to Sell Omnicare
CVS has entered into an agreement to sell its Omnicare LTC Pharmacy business to a partnership called GenieRx. The deal is expected to close later this year. CVS purchased Omnicare, the largest LTC Pharmacy in the US, in 2015, and recently saw Omnicare fined nearly $1 billion for False Claim Act violations. More
CVS Press Release
Amazon Pharmacy Will Offer Ozempic for Home Delivery
Online retail Giant Amazon will offer home delivery of Novo Nordisk GLP-1 weight loss medicine Ozempic. Amazon Pharmacy will offer the oral medicine for as little as $25 per month for patients with insurance coverage. More |
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