CMS Okays Acceptance of Part D Claims From Those Who Prescribe Under State Law

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By Mindy Yochelson

May 7 — The Centers for Medicare & Medicaid Services May 1 allowed some providers who aren't enrolled in Medicare to prescribe medications for enrollees in the Part D prescription drug benefit, after concerns that beneficiaries would be harmed if turned away at the drugstore counter.

The interim final rule with comment period (CMS-6107-IFC; RIN 0938-AS60) will allow beneficiaries to continue receiving medications prescribed by professionals who are prevented from enrolling in or opting out of Medicare but who may prescribe under state law.

The rule was published in the May 6 Federal Register (80 Fed. Reg. 25,958). Comments are due by July 6.

May 2014 Rule

The latest regulation makes some changes to a provision in a final rule published in May 2014 that required a Part D sponsor to deny claims if the physicians or other eligible professionals who wrote the prescriptions weren't enrolled in Medicare or didn't have a valid record of opting out.

At the time, the Medicare agency said requiring Part D sponsors to deny pharmacy claims from those prescribers would “help CMS ensure that Part D drugs are only prescribed by qualified individuals”.

Medicare plan industry representatives had expressed concern that enrollees would be harmed if their claims were rejected.

In the interim final rule, the agency said that it has since “learned that certain pharmacists and other provider types who do not meet the statutory definitions of ‘physician' or ‘eligible professional' to enroll in Medicare are permitted to prescribe under state laws.”

However, “without further action by CMS, valid prescriptions from these providers would be denied because the prescriber is neither enrolled in nor opted-out of Medicare.”

Preventing Interruptions

To prevent interruptions in coverage and harm to beneficiaries, the CMS said it would require that pharmacy claims and beneficiary requests for reimbursement for Medicare Part D prescriptions, written by prescribers other than physicians and eligible professionals who are permitted by state or other applicable law to prescribe medications, not be rejected at the point of sale.

The May 2014 rule had been effective as of June 1, 2015, although the CMS later said it would delay enforcement until Dec. 1, 2015.

The May 2014 requirements are now applicable on Jan. 1, 2016, at which point a Part D plan sponsor must reject, or require its pharmaceutical benefit manager to reject, a pharmacy claim for a Part D drug unless the claim contains the prescriber's National Provider Identifier (NPI), the CMS said.

The agency said it assumes that, as of Jan. 1, 2016, 250,000 prescribers will still need to enroll in or opt out of Medicare to prescribe Part D drugs, and it urged them to submit their enrollment applications as soon as possible.

The American Pharmacists Association in a May 4 posting called the rule “ a win for pharmacists and their patients.”

The group and seven others in a joint letter sent earlier this year told the CMS that, although “prescribing pharmacists” represent only a fraction of practicing pharmacists, “they provide invaluable access to care and medications, often for high-risk, medically-complex patients.”

Provisional Supply

On a related issue under the interim final rule, plans must allow a provisional supply of three months when a prescription is written by a prescriber who is eligible to enroll but who isn't enrolled in or opted out of Medicare. The plan must also provide individualized written notice to the beneficiary that the supply is being provided on a provisional basis.

The three-month provisional fill is intended to give the prescriber time to enroll or the beneficiary time to find a new prescriber, the CMS said.

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Ward Pimley at


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