On May 1, 2015, CMS issued an interim final rule with comment period revising certain requirements related to beneficiary access to covered Part D drugs.  This interim final rule modifies a prior final rule published on May 23, 2014, that requires prescribers of Part D drugs to enroll in or have validly opted out of Medicare.  Under these revised requirements, Part D sponsors will be permitted to pay pharmacy claims and beneficiary requests for reimbursement for Medicare Part D prescriptions that are written by certain pharmacists and other prescribers who do not meet the statutory definitions of “physician” or “eligible professional” to enroll in Medicare, but who are permitted by state law to prescribe medications. Under the interim final rule, such claims will not be rejected at the point of sale or denied by the Part D plan if all other regulatory requirements for writing the prescription are met.  

CMS further explained that a Part D plan sponsor will not be permitted to reject a claim or deny a beneficiary request for reimbursement for a drug when prescribed by a prescriber who does not meet the applicable enrollment or opt-out requirement without first providing provisional coverage of the drug and individualized written notice to the beneficiary.

The changes in this interim final rule apply starting January 1, 2016.  Comments are due by July 5, 2015.

A copy of CMS’s interim final rule is available by clicking here, and a copy of CMS’s related fact sheet is available by clicking here.  The interim final rule is scheduled to be published in the Federal Register on May 6, 2015.

Reporter, Ramsey Prather, Atlanta, +1 404 572 4624, rprather@kslaw.com.