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Medicare Prescription Drug Benefit Manual — Chapters 5 and 6


Email Alert

March 21, 2007

On March 9, 2007, the Centers for Medicare & Medicaid Services (CMS) released final versions of Chapters 5 and 6 of the Prescription Drug Benefit Manual. In promulgating the final version of the Chapters, CMS considered all of the comments received on the draft Chapters released in September 2006.

Chapter 5 addresses the issues of Benefits and Beneficiary Protections. The Chapter contains information about the following:

  • Part D benefits offered by Part D sponsors
  • Qualified prescription drug coverage (including standard and alternative prescription drug coverage) requirements
  • Incurred / "True Out of Pocket" (TrOOP) Costs
  • Establishment of Prescription Drug Plan sponsor service areas
  • Access standards for covered Part D drugs (including retail, mail-order, specialty pharmacy, and long term care pharmacy access)
  • Out of Network Access
  • Public disclosure to beneficiaries of pricing information for generic versions of covered Part D drugs
  • Privacy, confidentiality, and accuracy of enrollee records.

Chapter 6 addresses Part D Drugs and Formulary Requirements and includes information about the following:

  • Definition of a Part D Drug
  • Part D Drug Exclusions
  • Formulary Requirements for Part D Sponsors
  • Common Acute Care Home Infusion Drugs
  • Summary Tables showing Part D Drugs and Excluded Part D Drugs
  • Medicare Part B Versus Part D Coverage Issues
  • List of Formulary Key Drug Types Exempt from Drug List Review Check
  • Commonly Prescribed Drug Classes For Medicare And Dual Eligible Population

Chapters 5 and 6 may be revised in both periodic and annual updates. The Chapters currently reflect CY 2007 guidance. The Part D Task Force will soon be publishing more detailed guidance on Chapters 5 and 6 of the Prescription Drug Benefit Manual.

To access both Chapters 5 and 6, please click here.

We would like to thank Caroline Wade Blankenship (Miller Stratvert PA, Albuquerque, NM) and Scott Kiepen (Hooper Lundy & Bookman, Inc., San Francisco, CA) for providing this email alert.

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