PREVIOUS COVERAGE: Walgreens to go out-of-network for Dayton-based plan
CareSource Ohio Market President Steve Ringel said this is part of the insurer’s efforts to build a network of pharmacies that are willing to commit to payment models where they get paid for quality.
“They are putting more financial risk into the equation and putting their money where their mouth is and betting they can drive quality outcomes,” Ringel said.
Ringel said that many Ohio Medicaid members see their pharmacist more than they see their primary care doctor. CareSource officials said the firm wants to start paying pharmacists for more than just filling prescriptions now that the state has allowed pharmacists to get “provider status” and get reimbursed for performing more services.
“Every month if you’re on a maintenance prescription, you’re going having the opportunity to talk with a pharmacist. With provider status, they now can provide so much more with those point-of-sale opportunities and we’re so excited to leverage those opportunities,” Ringel said.
He said some examples of this could be medication reviews to make sure there aren’t complications coming from their prescriptions, or a pharmacist asking screening questions about whether the patient has food and shelter, answers to which could bring CareSource to provide them other services.
Roxanne Richardson, deputy director of Ohio Medicaid’s Office of Managed Care, said in a Nov. 13 letter approving the change that CareSource “has detailed a transition plan including early notification to members and prescribers, transitioning member prescriptions beginning with ODM’s (Ohio Medicaid) approval and data analysis of claims denials and subsequent claim approvals.”
MORE: Bellbrook man’s data crunching driving big pharmacy change
The letter said that “CareSource informed us that Walgreens would be willing to continue a business relationship with them, if CareSource would eliminate other pharmacies from its network. Should CareSource maintain Walgreens within their pharmacy network some counties could experience access issues if they eliminated other pharmacies (e.g. grocers) in an effort to maintain Walgreens.”
Pharmacy benefit scrutiny
Pharmacy benefit management was once an obscure layer in the state’s $28 billion Medicaid program. But for more than two years, some pharmacists, legislators and other state officials have been digging into exactly how the state spends $3 billion in pharmacy benefits and whether too much of that money is being kept by the private companies that manage those benefits.
Pharmacy benefit managers — the companies that perform this role for insurers — have said they bring value and efficiency, as well as negotiate discounts on expensive prescriptions.
Ohio Medicaid has started some major changes including making an unprecedented amount of pharmacy spending data available, and creating a single, consistent list of preferred medications across the state.
The debate over pharmacy benefits flared back up when the news came out that CareSource was moving Walgreens out of network. Walgreens is one of the largest pharmacy chains in the area, listing 24 stores in the Dayton metro area.
MORE: Ohio Medicaid sees initial success overhauling $3B drug program
A Walgreens spokeswoman has said CareSource “has decided to move forward with a network that does not include Walgreens for Ohio managed Medicaid patients in 2020.” Walgreens is also still in-network for two other Medicaid plans in Ohio, UnitedHealthcare Community Plan and Paramount Advantage.
Ohio Department of Medicaid members can get enrollment help by calling 1-800-324-8680. CareSource members will be notified they they have the option to select a different plan if they believe CareSource can no longer meet their needs as a result of this change.
According to CareSource pharmacy data, the Walgreens exit impacts approximately 90,000 members who use the pharmacy for routine maintenance medications or medications used to treat chronic conditions.
CareSource said 99 percent of all Ohio Walgreens locations have a CareSource in-network pharmacy located in close proximity, within no more than 2.2 miles.
Now that the change has been finalized with Ohio Medicaid, CareSource members will receive a letter highlighting nearby pharmacy options.