Contract Year 2014 Part D Formulary Administration Analysis
CMS released a memo providing information about an analysis that will evaluate whether Part D sponsors are appropriately adjudicating Medicare Part D drug claims consistent with Part D requirements and sponsors’ CMS-approved benefits. The memo also describes the methodology that will be used by CMS to complete the monitoring process for this program.
Note: CMS initiated the CY2014 analysis due to their concerns with results from the 2013 formulary administration analysis. Unlike 2013 where only select sponsors had to provide claims, for 2014, CMS broadened the scope of eligible plans. Unless your plan is already identified to undergo a program audit in 2014 or if you participated in BOTH a program audit and Formulary and Benefits Administration validation audit in 2013, expect to receive a request.
Recommended Action: Review the attached memo for details. Information regarding the types of rejected claims (i.e. non-formulary, prior authorization, step therapy, and quantity limits) as well as the date ranges based on plan size are included within the methodology section.
CMS expects a 48-hour turnaround time on providing the data, so request the data NOW from your PBM and begin review of the claims to identify any potential issues. June 2014 data will be used.
For questions regarding data extraction, submission, or the secure website, please contact Acumen at FormularyBenefits@AcumenLLC.com. For questions regarding Formulary Administration Analysis, please contact LeAnn Poole at firstname.lastname@example.org or Réna McClain at email@example.com.