Medicare Part D: Star measures changes are coming

This year, Part D plans with a rating of less than four stars will lose out on $3.47 billion in bonus payments.1 Star Ratings continue to have a huge impact on plan success. When it comes to Medicare Part D, Prime’s solutions can impact Star Ratings Program measures.

The Centers for Medicare and Medicaid Services (CMS) has approved significant changes to the Star Ratings Program. Prime is taking action to address these changes.

  • CMS has stopped measuring members with diabetes who are taking an ACE/ARB to help control blood pressure or end-stage renal disease: GuidedHealth® ran the ACE/ARB program through the end of March 2015 as part of the Medicare program. 
  • Measure the use of statins for members with diabetes (display measure in 2015, Star Rating in 2016): Starting in 2Q2015, GuidedHealth will offer the statin diabetes mellitus program each quarter. Prime will assess this population and determine which new products should be created to meet 4-Star levels.
  • Remove the requirement for beneficiary consent before shipping medicines: PrimeMail® is reviewing options to remove or change the consent requirement. This should make it easier and more convenient for members to get their medicines. PrimeMail will consult with clients to tailor this feature to their needs – we know there’s not an all-or-nothing solution.
  • Reduce the over-use of opioids and minimize false positives: Prime is identifying and making system and operational improvements to our drug utilization review system, and developing morphine equivalent dose (MED) parameters.
  • Ensure preferred cost-sharing pharmacies (PCSPs) meet urban access requirements: Our provider choices include chains, grocers and independent pharmacies for our Preferred Medicare networks. We make preferred pharmacy access as easy as possible for members.

CMS is also calling on plans to continue to help improve health outcomes in 2016. Knowing that member and provider outreach is key to improving health outcomes, Prime:

  • Gives members 24/7 access to experts. This makes it easier, more convenient and more affordable for members to get the medicine they need. Convenience and affordability are two drivers for better adherence and better outcomes.
  • Makes sure that providers have the actionable, accurate information they need to make smart medicine decisions. Better medication decisions can lead to health improvements.

CMS may look at more changes in 2016, such as additional measures for:  

  • Asthma
  • Depression
  • Preventable hospitalizations
  • Patient-reported outcomes

Prime is taking action now to address changes for 2016 and beyond. We will continue to enhance our solutions and develop new ways to help you receive the best Star Rating possible.


1McKinsey Center for U.S. Health System Reform. (October 2014). Assessing the 2015 MA star ratings.


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