CMS published an interim final rule with comment period (IFC) on May 6, 2015 that modifies a previously-adopted regulatory requirement regarding qualifications to prescribe Part D drugs. By way of background, under a final rule published May 23, 2014, Part D sponsors must deny a pharmacy claim for a Part D drug if the physician or eligible professional who wrote the prescription is neither enrolled in nor validly opted-out of Medicare. CMS previously announced that it was not enforcing the enrollment requirement until December 2015 to allow additional time for Part D prescribers to enroll in or opt-out of Medicare.
CMS has subsequently learned that certain pharmacists and other provider types who do not meet the statutory definitions of “physician” or “eligible professional” to enroll in Medicare may prescribe drugs under state law, but their prescriptions would be denied under the CMS rule because the prescriber is neither enrolled in nor opted-out of Medicare. In response, the May 6 IFC provides 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, will not be rejected at the point of sale or denied by the plan if all other requirements are met. In addition, to mitigate potential interruptions to beneficiaries’ access to medications, the IFC requires Part D sponsors to cover a provisional supply of drugs (3 months) and provide beneficiaries with individualized written notice before denying a Part D claim or beneficiary request for reimbursement on the basis of a prescriber’s Medicare enrollment status. The IFC applies the enrollment policy effective January 1, 2016. Comments will be accepted until July 6, 2015.