What Every Pharmacist Should Know about Medicare Part D
First and foremost, it is important to realize that Medicare Part D - the prescription drug benefit is here - effective
January 1, 2006.
It redefines much of
the way retail pharmacy operates and the profession of pharmacy. The
best thing a pharmacist can do is be prepared and explore opportunities
to make the most of the changes.
Information will be regularly added to this website. Plan to check
Medicare Prescription Drug Updates
CMS Posts Medicare Part D Plan Level Enrollment
Friday, July 28, CMS posted Part D plan-level enrollment data for Medicare
Advantage (MA), Cost, PACE, Demo, and Prescription Drug Plan (PDP) to
the its website. This data reflects enrollment counts that were paid
for the month of July 2006. Please carefully review the technical notes
appearing at the top of the worksheet.
Plan-level data will be posted once a year during the month following
the conclusion of the MA open enrollment season. Barring any legislative
changes, interested parties can expect the next plan-level enrollment
data in June 2007, following the end of MA enrollment season on April
All other months of the year, CMS will post MA and Part D enrollment
data at the contract level. Additionally, CMS will post a summary of
enrollment by organization type.
The Annual Report by Plan is available in the "downloads" section at:
Message from CMS (7/10/06): Erectile Dysfunction Medications
Q: Are Erectile Dysfunction (ED) drugs covered under Part D?
A: For Contract Year (CY) 2006 ED drugs met the definition of a Part
D drug and were available on Plan Sponsor formularies. On October 26,
2005, Section 1860D-2(e)(2)(A) of the Social Security Act (the Act)
was amended excluding from the definition of a Part D drug, “a drug
when used for the treatment of sexual or erectile dysfunction, unless
such drug were used to treat a condition, other than sexual or erectile
dysfunction, for which the drug has been approved by the Food and Drug
Subsequently, beginning CY 2007, ED drugs,
when prescribed for the treatment of sexual or erectile dysfunction,
will be excluded from coverage under Part D
As with other excluded drugs, Part D sponsors may only continue coverage
of ED drugs as long as they do so as supplemental benefits through enhanced
alternative coverage. In addition, ED drugs will meet the definition
of a Part D drug when prescribed for medically accepted indications approved
by the FDA other than sexual or erectile dysfunction such as pulmonary
hypertension. However, ED drugs will not meet the definition of a Part
D drug for other off-label uses not approved by the FDA. This includes
non-FDA approved uses included in one of the compendia listed in section
1927(g)(1)(B)(i) of the Act : American Hospital Formulary Service Drug
Information, United States Pharmacopeia-Drug Information, and DRUGDEX
In the next few days, pharmacists will inevitably have to serve some
Medicare beneficiaries who have enrolled in a plan or switched plans
late in February. As a result, some of these beneficiaries may not yet
be identified in pharmacy systems. As a reminder to pharmacists, we are
once again sending instructions for using the eligibility (E1) functionality
to check on plan enrollment and Medicare eligibility status. Per-Se Technologies
optimizing the E1. For more information you may visit their Medicare
, or contact your software vendor. For beneficiaries
who are eligible for both Medicare and Medicaid but who do not appear
to have been enrolled in a plan, we are also sending instructions for
using the Point of Sale Facilitated enrollment process. This process,
known as the "Wellpoint Point of Sale solution," will allow pharmacies
to submit claims to Wellpoint for a dual eligible beneficiary who does
not appear to be enrolled in a plan so the beneficiary will not have
to leave the pharmacy without the medications they need. An
can be found at Anthem Prescription's Part D
Medicare Part D/B Helpful Documents
Part D Versus Part B Coverage Issues
How to Become a Part B Supplier:
CMS website has a special section on enrolling as a Medicare supplier
or provider on its website at
The website contains a 2-page brochure that provides a brief overview
on enrolling in the Medicare program as a provider or supplier (
You can also download enrollment forms directly from the website
In order to help simplify the process of Part D plans and pharmacists
determining whether a drug should be billed to Part D or Part B,
CMS has sent the following letters to Medical specialty groups in
the areas of oncology, hematology, transplants, and rheumatology,
and to long-term care associations.
What each and every pharmacist should do - Six Key Steps
1)Be prepared -- Focus on learning as much as possible about
the Benefit. You only have a few days - so start NOW!
Go to CMS website with
Read the articles in the Drug Coverage Series.
They are relatively short - 2 to 3 pages.
Visit the CMS specific section for
CMS has posted additional information about the new benefit including
an educational video tool specifically for pharmacists that can help
answer questions about implementation. The video tool as well as
additional information is now available on the CMS website (
The video covers details on the new E1 eligibility transaction, instructions
on billing for Katrina evacuees and facilitated point of sale enrollment
of dual eligibles, as well as other pharmacy related topics of interest.
Save this list of
to help you understand the benefit
The Pennsylvania Pharmacists Association has added an
list of key terminology
Here is a list of terms to help in talking to patients about the
CMS offers an acronym search engine
NASPA has a list of
courses so you can earn CE while learning about the
. So you can check for additional information frequently.
are available from CMS that
are updated frequently.
Consider participating in CMS Open Forums to hear from and ask
questions of CMS leadership on topics of interest to your particular
provider type; for information about these forums visit
Sign-up to receive email notification of new information
for pharmacies and pharmacists about the Medicare Modernization
Act and Medicare Prescription Drug Coverage.
here for access and to sign up for the CMS mailing list
2)Specifically understand the low income benefit and promote
it to seniors who may qualify. Seniors who may qualify for this need
to apply NOW!
3) Determine to what extent your pharmacy might be ready and
interested in providing Medication Therapy Management Services (MTMS).
4)Work with your Medicare
eligible patients to promote plans that will work for both them and
Sheet for Beneficiaries
with the notices mailed out - per section 2 above)
- Posters titled
Income? Social Security Can Help with Prescription Costs"
be ordered free of charge on the Centers for Medicare and Medicaid
Services (CMS) website. The posters direct Medicare beneficiaries
with low income to a toll free number where they can find out if
they are eligible for help with prescription drug costs. The posters
are suitable for display in a pharmacy, Order the size and style
appropriate for your use. To view and order the posters, go to
the CMS website.
Review the scripts being used by 1-800-MEDICARE. These scripts
are posted for your reference and to understand what call center
customer service representatives are telling beneficiaries. As the
scripts are modified, updates will be posted to this website. You
can find the scripts at
on the CMS website.
5) Get your NPI as an
CMS is pleased to announce the availability of a new identifier
for use in the standard electronic health care transactions. The
National Provider Identifier (NPI) will be the single provider identifier,
replacing the different provider identifiers currently in use for
each health plan with which they do business. Obtaining the NPI
is required in the Health Insurance Portability and Accountability
Act of 1996 (HIPAA) and will be the single national provider identifier
for pharmacists, pharmacies, and prescribers no later than May 23,
National standards for electronic health care transactions encourage
electronic commerce in the health care industry and simplify the
processes involved to reduce the administrative burdens on health
care providers. A May 6th letter (linked below) was distributed
to aid in understanding the background of this requirement & what
steps are necessary to apply for and receive your NPI.
go directly to
Obtaining your NPI is recommended for individual pharmacists now. Pharmacies
may wish to hold off on this process
The NPI is the first opportunity
for pharmacists to have an individual provider number with which
to bill third parties.* This includes billing prescription drug plans
(PDPs) for medication therapy management services (MTMS) under the
Medicare Part D drug benefit. Pharmacists are encouraged to obtain
an individual NPI. This is a new opportunity for pharmacists. The
provider identifier number does not guarantee that payment will be
provided, but may be required by payers in the future.
For pharmacies, the NPI will replace
all other provider identifiers, for example, such as the NCPDP pharmacy
ID number, formerly the NABP number presently required by health
Before you pursue a NPI for your pharmacy
you should be aware of an upcoming initiative by the National Council
for Prescription Drug Programs (NCPDP). Under NCPDP’s guidance, the
pharmacy industry is currently developing a transition plan to move
pharmacies from the NCPDP number to the NPI over the next two years.
NCPDP plans to submit its application to CMS to be a bulk NPI enumerator
in late summer. Once its application is approved, NCPDP will contact
pharmacies and request authorization to become their agent in obtaining
their NPI. NCPDP will then work with CMS and obtain NPIs for all
authorizing pharmacies no later than May 2006, giving processors
and pharmacies a full year to test and implement the NPI before the
required implementation date of May 23, 2007. NCPDP requests that
you delay your pharmacy’s application for an NPI until this fall
when NCPDP has been certified to obtain NPIs on behalf of pharmacies.
If you authorize NCPDP to obtain a NPI on behalf of your pharmacy,
your new NPI and current NCPDP number will automatically be disseminated
to the pharmacy industry (including payers). This will ensure your
claims process normally with minimal disruption. NCPDP will not charge
any fees for its enumeration activities on your behalf. For more
information on this initiative, visit
Enumeration update(added from NCPDP
Pharmacies and individual pharmacists are advised in
not to use the NPI until health
plans and PDPs have issued specific instructions on accepting
the NPI, which could begin prior to but no later than May 23,
Beginning May 1, 2006, the Centers for Medicare & Medicaid
Services (CMS) announces the capability for health industry organizations
to submit health care providers' applications for National Provider
Identifiers (NPIs) to the National Plan and Provider Enumeration System
(NPPES) via Electronic File Interchange (EFI). With EFI, a CMS-approved
health industry organization can submit a health care provider's NPI
application data, along with the application data of many other health
care providers, in a single electronic file in a CMS-specified format.
EFI is an alternative to health care providers having to apply for
their NPIs via the web-based or paper application process. After the
NPPES processes a file, it makes available to the organization a downloadable
file containing the NPIs of the enumerated health care providers. Interested
health industry organizations should avail themselves of the EFI materials
available from the CMS NPI page (
and from the NPPES page (
before downloading and completing the Certification Statement (available
and registering as EFI Organizations. A completed Certification Statement
must be approved by CMS before an interested health industry organization
can participate in EFI.
6) Medicare Updates
Benchmark Fact Sheet (Final)
to Benefits Coalition Statement
Patient Assistance Programs
On Wednesday, the Centers for Medicare & Medicaid Services posted
on its website guidance outlining how pharmaceutical company patient
assistance programs can work with Medicare Part D in light of a recent
Office of the Inspector General Bulletin (November 22, 2005).
There is nothing in the law that prohibits a pharmaceutical company
from making a patient assistance program available to Medicare beneficiaries
-- even beneficiaries who have enrolled in a Part D plan. The decision
to keep a patient assistance program, as well as the terms of the program,
are up to the pharmaceutical company, not the US government. However,
any assistance provided to a Part D enrollee must be clearly outside
of the Medicare Part D program and would not count as Part D "true out-of-pocket" spending
by the beneficiary
CMS will work with companies interested
in entering into a voluntary data sharing arrangement with CMS, in accordance
with the OIG guidance, to facilitate coordination of benefits. Pharmaceutical
companies also have the option to make cash donations to bona fide, independent
charities that assist Medicare beneficiaries with out-of-pocket drug
CMS understands the value that pharmaceutical patient assistance programs
provide to many financially needy individuals, including those with Medicare.
Individuals currently without drug coverage who are eligible for Medicare
should consider enrolling in a Medicare prescription drug plan that meets
their needs. In addition, beneficiaries who think they may be eligible
for extra help may file an application with the Social Security Administration
for the Part D limited-income subsidy. These steps will ensure that
people have access to the prescriptions they need.
The guidance, which provides more detail about this issue, as well as
an example of how this would work for a Medicare beneficiary can be accessed
Also, attached is a letter from HHS' Physicians' Regulatory Issues Team
with valuable information for providers about how to assist beneficiaries
with appeals, coverage determinations and exceptions as well as other
general information about Medicare Prescription Drug Coverage.
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