Earlier this year, CMS issued its Medicare Part D Final Rule addressing DIR fees, among other things. It is important to remember that the rule does not eliminate DIR fees but moves them to the point of sale. The rule becomes effective January 1, 2024, meaning that the pharmacies will face a DIR cliff when
Medicaid & Medicare
What the Inflation Reduction Act means for pharmacies
Earlier this year, the Senate passed the Inflation Reduction Act (a.k.a. Build Back Better Act) which was heavily covered in press. I will only focus on what the Act has in store for pharmacies and will highlight the most important provisions for the pharmacy industry.
The Act – at its core – gives CMS ability…
Improper use of collaborative practice agreement costs $831,000 to 3 Florida pharmacies
The United States Attorney’s Office for Southern District of Florida has recently announced a settlement with three Florida pharmacies to resolve allegations that they fraudulently used collaborative practice agreements (“CPAs”) to bill federal health care programs for unlawfully prescribed medications.
In its press release, the governments explains that “A collaborative pharmacy practice agreement is…
California pharmacies will no longer be required to pay back the state under its new reimbursement methodology
Back in 2017, the California Department of Healthcare Services (DHCS) approved a new methodology – National Average Drug Acquisition Cost (NADAC) – for reimbursing pharmacies for their drug cost. NADAC prices significantly reduced pharmacy reimbursements. See a related blog post.
For technical and financial reasons, the DHCS has not implemented the new reimbursement methodology until…
Medi-Cal Rx Training
I receive many questions regarding the transition to Medi-Cal Rx (a new California Medicaid program for processing pharmacy claims). The Department of Healthcare Services has just announced its Medi-Cal Rx training program for pharmacies and prescribers. If you bill Medi-Cal, I strongly suggest that you take advantage of this resource.
The training consists of three…
Transition to Medi-Cal Rx is postponed
The announced Medi-Cal Rx implementation date, which was initially set for April 1, 2021, is postponed. (See a related Blog Post).
Magellan Haelth, Inc – a PBM that will administer the program – is in the process of being acquired by Centene Corporation. Centene operates managed care plans and pharmacies that participate in the…
Medi-Cal Rx Update
The California Department of Healthcare Service (DHCS) has just posted an update regarding Medi-Cal Rx transition (See Related Blog Post). In anticipation of this transition, there are some early cutoff activities that California pharmacies should note:
- Pharmacy Paper Claim Submitters: The cutoff for claims processing for paper claim submissions to the current
Updates on the Medi-Cal transition. Test claims, exemptions, and changes
The transition date of Medi-Cal managed care claims to fee-for-service is still set for April 1, 2021.
Medi-Cal Rx – the name of the new program – will apply to all pharmacy services billed on pharmacy claims. However, most DME claims are exempt. For a complete list of exempt products, visit Medi-Cal Rx website.…
Mandatory e-prescribing for Part D
The SUPPORT Act (Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act) requires that controlled substances prescriptions covered under Medicare Part D be transmitted electronically. The effective date for compliance was set for January 1, 2021. Does this mean that pharmacies can no longer accept paper/faxed prescriptions?
First of all,…
Manufacturers exiting 340b program
Since the inception of the 340b program, drug manufacturers have been attempting to curtail it to avoid offering discounts or to prevent double discounts (which occurs when a 340b drug is billed to a Medicaid program). This year, however, there were multiple coordinated attempts by manufacturers to exit the program. For example:
- AstraZeneca will stop