Pharmacies participating in the Medicare prescription drug program will be mandated to electronically submit their Part D prescriptions to their Part D sponsor under a final rule published on April 15.

The rule makes policy and technical changes to the Medicare Advantage and Medicare prescription drug programs for calendar year 2011. The Part D prescriptions must be electronically sent to plan sponsors "unless the enrollee expressly requests that a particular claim not be submitted to the Part D sponsor or its intermediary," according to the rule from the Centers for Medicare and Medicaid Services.

The agency included the mandate after becoming aware "of an increasing number of instances in which network pharmacies are not submitting claims to Part D sponsors on behalf of Part D enrollees," CMS states in the final rule. "Generally, we believe it is in the best interest of Part D enrollees to have their claims consistently processed through the Part D sponsor (or its intermediary). Not only does processing claims through the Part D sponsor ensure access to Part D negotiated prices, but it also ensures that proper concurrent drug utilization review (including safety checks) is performed. In addition, online, real-time processing facilitates accurate accounting for enrollees' true out-of-pocket and total drug costs by the Part D sponsor so that each claim is processed in the appropriate phase of the benefit and accurate cost sharing assessed."

The rule is available in the April 15 Federal Register at

--Joseph Goedert


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