Appeal type: unknown
Decision: unknown

Under Medicare rules, Part D sponsors must provide enrollees with access to negotiated prices for covered Part D drugs as part of their qualified prescription drug coverage. This access to negotiated prices must be provided even when no benefits are otherwise payable on behalf of an enrollee due to the application of a deductible or other cost-sharing. Negotiated prices will take into account negotiated price concessions for covered Part D drugs that are passed through to enrollees at the point of sale, such as: 1) Discounts; 2) Direct or indirect subsidies; 3) Rebates; and 4) Other direct or indirect remunerations. In addition, negotiated prices must include any applicable dispensing fees. Although negotiated prices do not have to be made available for drugs that are not covered Part D drugs, they must be made available throughout the benefit  including in any phase of the benefit, such as the deductible, in which an enrollee is responsible for 100 percent cost-sharing  for all covered Part D drugs. The Part D sponsors must ensure that their payment systems are set up to charge beneficiaries the lesser of a drugs negotiated price or applicable copayment amount in all phases of the benefit. In addition, uniform negotiated prices must be available to plan enrollees for a particular covered Part D drug when purchased from the same pharmacy. In other words, the negotiated price for a particular covered Part D drug purchased at a particular pharmacy must always be the same regardless of what phase of the Part D benefit an enrollee is in. [The Centers for Medicare & Medicaid Services Internet-Only Manual, Publication 100-18, Medicare Prescription Drug Benefit Manual, Chapter 5, Section 20.6]Medicare rules specifically address the requirement for Part D sponsors to issue standardized cards that may be used by an enrollee to ensure access to negotiated prices. The only way that an enrollee can be assured access to the negotiated price at the point of sale is through online adjudication of the prescription drug claim. Therefore, to ensure access to these negotiated prices, the billing information on the standardized cards issued by the Part D sponsor must be used by the pharmacies at which beneficiaries fill their prescriptions to submit claims to an enrollees plan sponsor (or its intermediary). Thus, another price available to the beneficiary at the point of sale, for instance, the pharmacys cash price, would not be the negotiated price because it is not accessed by the use of the standardized card. Part D sponsors must require their network pharmacies to submit claims to the Part D sponsor or its intermediary whenever the Part D member identification card is presented or is on file at the pharmacy unless the enrollee expressly requests that a particular claim not be submitted to the sponsor or its intermediary. Many benefits accrue to on-line adjudication of prescription drug claims. Not only is it the only way to ensure that enrollees have access to the plans negotiated price at the point of sale, it also: 1) Ensures that proper concurrent drug utilization review (including safety checks) is performed; 2) Promotes accurate true out-of-pocket accounting; 3) Minimizes administrative costs to the Part D sponsors and the Medicare program; and 4) Limits opportunities for fraudulent duplicative claim reimbursements. For cash purchases made at in-network pharmacies, the Centers for Medicare & Medicaid Services expects the enrollee to be responsible for the difference between the cash price and the plans negotiated price. Part D sponsors must provide enrollees with access to negotiated prices used for payment of covered Part D drugs. This requirement limits sponsor reimbursement to the negotiated price for the drug. Although the Centers for Medicare & Medicaid Services believes that use of the Part D benefit is in the best interests of beneficiaries and the Medicare program, the agency also recognizes there may be circumstances when a cash purchase is reasonablesuch as when the pharmacy offers discounted prices through, for example, loyalty programs or pharmacy coupon offers that are not subsidized by purchases of drugs covered by Part D  and these prices may be lower than a Part D sponsors negotiated price. Beneficiaries may take advantage of such offers, but the receipt must reflect the actual price paid and the member must submit a request for reimbursement to the plan. In these instances, the plan sponsors reimbursement will be based on the amount paid for the covered Part D drug if purchased at either a network pharmacy or an out-of-network pharmacy. [42 Code of Federal Regulations Section 423.120 and the Centers for Medicare & Medicaid Services Internet-Only Manual, Publication 100-18, Medicare Prescription Drug Benefit Manual, Chapter 14, Sections 50.4.3 and 50.4]