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.