Medicare Updates for Pharmacists
Updated October 18, 2011

10/18/11

Medicare Information for Pharmacists - Download the Memo from CMS

2/22/11
Clarification of Exclusion of Part D Payment for Drugs Included in the End-Stage Renal Disease Prospective Payment
CMS issued the attached guidance to Part D Plan Sponsors clarifying the exclusion of Part D payment for drugs included in the new ESRD payment system.  The memo clarifies which drugs are always ESRD payment related and those which may be ESRD payment related, and also provides specific Part D payment guidance to Part D Plan Sponsors to ensure ESRD patient access is not inappropriately restricted at the point-of sale.  Please see the attached memo for a detailed discussion on each of these topics.

1/1/11
Upgrades to the CMS TrOOP Facilitator
As experience with the Medicare Part D program has grown, CMS continues to explore areas that offer opportunities for improvement. As part of this effort, the TrOOP Facilitation contractor will implement new matching logic for the Medicare eligibility query (E1) to identify a Medicare beneficiary’s Plan enrollment information. Use of the enhanced matching logic will enable the TrOOP Facilitator to provide pharmacies with more accurate information by decreasing the probability of false positive matches as well as the need for pharmacy reprocessing of the claims associated with the mismatches.  Therefore, effective January 1, 2011, pharmacists MUST include at a minimum the following patient information in the E1 request for a match to occur:
1. Cardholder ID, which can be any one of the following:
     a. Medicare Part A/B ID Card Number;
     b. Nine-digit Social Security Number (SSN);
     c. Railroad Retirement Board (RRB) number; or
     d. Last four digits of the SSN;
2. Patient Last Name;
3. At least the first character of the Patient First Name;
4. Patient Date of Birth.
Please note, if all required information is not provided, the E1 response will be ““Missing Required Field” even if the submitted Cardholder ID information is correct. Payer sheets and an explanation of the changes will be available on the TrOOP Facilitation website at http://medifacd.relayhealth.com.  A tip sheet describing these changes is attached.

12/10/11
CMS Posts 2011 Non-Matched NDC List
CMS has posted an update to the CY2011 Non-matched NDC list to reflect the newest FDA NDC Directory listings.  CMS will use this updated list to implement PDE reject edits for dates of service beginning January 1, 2011.  CMS expects Part D sponsors to rely on the monthly updates to the FDA NDC Directory to determine when NDCs get listed and not wait for CMS to update the Non-matched NDC list.  The updated list can be found at: www.cms.hhs.gov/PrescriptionDrugCovContra/03_RxContracting_FormularyGuidance.asp

11/26/08

CMS Issues a Reminder to Plans on Long-Term Care Pharmacy Contracting
CMS issued a reminder to all Part D Sponsors yesterday of the requirement to 1) provide convenient access to network long-term care (LTC) pharmacies to all of their enrollees residing in LTC facilities, and 2) exclude payment for drugs that are covered under a Medicare Part A stay.

In the notice, CMS reminds sponsors that in order to remain compliant with their convenient access requirements, sponsors must either contract with the LTC facility’s contracted pharmacy or provide the enrollee with covered Part D drugs via another network LTC pharmacy.  Encouraging enrollees to enroll in another plan during the annual open election period, or through the special election period for institutionalized beneficiaries, in lieu of contracting with an LTC pharmacy to provide covered Part D drugs to a facility’s residents is not permitted. Such activities on the part of either the LTC care facility or LTC pharmacy are also prohibited, and may violate other federal laws.

Furthermore, CMS reminds sponsors  that they will be out of compliance with uniform benefits requirements to the extent that they agree to particular contracting terms and conditions that have the net result of creating a non-uniform benefit for plan enrollees residing in certain LTC facilities. It is very important that, as sponsors negotiate with LTC pharmacies for inclusion in their networks, they are acutely aware that they cannot agree to differential benefits that would result in non-uniform benefits among enrollees in LTC facilities (e.g., extended transition periods, certain utilization management edits, or different drug utilization review protocols limited to LTC enrollees obtaining their drugs from a specific LTC pharmacy).

Plan Reporting of LTC Pharmacy Rebate Data
CMS released a memo on November 24 informing Part D plans that they are suspending the current collection of LTC rebate reports for CY2008 and CY2009 in lieu of a new reporting requirement that will be changed, effective in 2010.  Additionally, CMS announced in the memo their intention to test the proposed reporting requirements with a small number of Part D sponsors prior to 2010.  Please see the attached memo (mc_memoLTCRebateRptChange_112408.pdf) to view the proposed new reporting requirement for CY2010, as well as information about the timing of Part D reporting requirements and the public comment process.

MemoERx_09.19.08.pdf

Supporting Electronic Prescribing under Medicare Part D 

CMS released a memo (click link above) to Part D Sponsors today providing details about our expectations for supporting e-prescribing, particularly with respect to the “initial” e-prescribing standards that become effective April 1, 2009.  The memo provides context and background on the foundation and initial standards, and on the changes expected to be brought about by the Medicare Improvements for Patients and Providers Act of 2008.  We specifically address our expectations details for implementation of the NCPDP Formulary and Benefits 1.0 standard, the NCPDP SCRIPT 8.1 Medication History standard, NCPDP SCRIPT 8.1 Prescription Fill Status Notification (RxFill) standard and requirements for the Individual Prescriber NPI. 

And Ensuring Adequate Network Pharmacy Participation

E-prescribing in Part D will not be successful -- and e-prescribers will become frustrated -- if pharmacies are not willing or prepared to implement e-prescribing. While we believe a significant number of pharmacies currently support e-prescribing and comply with the Part D e-prescribing standards, we understand Part D pharmacy access standards may be jeopardized if sponsors were to contractually mandate all network pharmacies to support e-prescribing as a condition of participation in their network. Thus, as outlined in Chapter 7 of the Prescription Drug Benefit Manual (Section 50.1), Part D sponsors must allow for exceptions to network pharmacy support for e-prescribing when it is either impractical or otherwise could jeopardize beneficiary access. 

Additionally, we clarify that we consider the costs incurred by network pharmacies to implement e-prescribing and transmit and receive e-prescribing transactions for Part D covered drugs prescribed to Part D eligible individuals to be legitimate Part D overhead costs that should be a factor in developing dispensing fees. It is unlikely that dispensing fees negotiated prior to a pharmacy’s implementation of e-prescribing factored into these costs. Therefore, we would expect Part D sponsors to review network dispensing fees to ensure they appropriately reimburse pharmacies for these new costs.  Alternatively, Part D sponsors could both address these new costs and incentivize pharmacies to implement e-prescribing by paying differential dispensing fees.

1/4/07
Reminder: Substitution of Generic Drugs (click link for details)

12/27/06
Medicaid Drug Pricing Regulation Proposed
HHS Secretary Mike Leavitt announced proposed changes in the payment for certain prescription drugs in the Medicaid program.  These changes implement provisions of the Deficit Reduction Act of 2005 (DRA) and are expected to save taxpayers $8.4 billion in state and federal funds over five years.  To view the entire CMS Fact Sheet, please click here: http://www.cms.hhs.gov/apps/media/fact_sheets.asp . A copy of the Regulation Text can be found at: http://www.cms.hhs.gov/MedicaidGenInfo/downloads/AMP2238P.pdf

11/17/06
Medicare Prescription Drug Plan Guide: How to Choose Your 2007 Plan
Workbooks are available to pharmacies. The workbook was produced through a collaborative effort of NACDS, NCPA, and American's Health Insurance Plans (AHIP).  There are several ways you can obtain copies of these books for potential distribution to your Medicare patients:

• Free copies - A limited quantity of workbooks are are available to pharmacies.  Boxes of 60 are available on a "first come, first serve" basis.  Send an email to Elizabeth.brooks@ahip.org to obtain your free copies.

• Pharmacies can also obtain a high-resolution PDF (Adobe Reader) version of the workbook to print additional copies.  Pharmacies can "co-brand" the books by placing their logo on the back.  Please contact Susan Pisano at spisano@ahip.org.

• Pharmacists can direct their patients to the website www.healthdecisions.org/guide where they can view the workbook themselves, print out their own PDF version, or use an online, interactive version of the workbook.

11/6/06
Medicare Update: PowerPoint Presentation

Webpage and Listserv Information
State MMA Webpage: http://www.cms.hhs.gov/States/. Please email feedback and suggestions in regards to the State MMA Webpage to MMAStatesWebsite@cms.hhs.gov.  To subscribe to this listserv, go to http://www.cms.hhs.gov/apps/mailinglists/default.asp?audience=14 . Enter your information, then select the appropriate list serve "MMA_States" and choose subscribe. To unsubscribe from this listserv, go to http://www.cms.hhs.gov/apps/mailinglists/default.asp?audience=14 . Enter your information, then select the appropriate list serve "MMA_States" and choose unsubscribe.

4/11/06
Medicare Survey Polls Nearly 6,000 Pharmacists - 88% call for immediate improvements in Part D program.
In a comprehensive survey of nearly 6,000 pharmacists only 119 called the new Medicare Part D prescription drug program a success. Pharmacists from across the country expressed their views through a survey conducted by the Pharmacy Society of Wisconsin on behalf of the National Council of State Pharmacy Association Executives (NCSPAE). Read the Press Release. Download Full Report  
 

2/3/06
Testimony of Pharmacist at U.S. Senate Special Committee on Aging: "Meeting the Challenges of the Medicare Drug Benefit Implementation"