As required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, CMS established electronic prescribing standards to facilitate the communication of prescription information among prescribers (e.g., physicians), Part D plan sponsors, and dispensers (e.g., pharmacies). Three of these standards enable the flow of eligibility, medication history, and formulary and benefits information between plan sponsors and prescribers at the point of care.
These plan-to-prescriber standards are (1) Accredited Standards Committee X12N 270/271, (2) SCRIPT 8.1, and (3) Formulary & Benefits Standard 1.0. The Formulary & Benefits Standard 1.0 consists of four components: (1) Formulary Status List, (2) Formulary Alternatives List, (3) Coverage List, and (4) Copayment List.
CMS required that plan sponsors implement two standards by January 2006 and the remaining standard by April 2009. Between August and September 2008, the Office of Inspector General (OIG) surveyed all Part D plan sponsors for plan year 2008 to determine the extent of their implementation of the standards. The OIG received responses from 262 plan sponsors for a 94 percent response rate.
Survey results. The OIG survey found that: (1) nearly 80 percent of plan sponsors reported at least partial plan-to-prescriber connectivity but few reported complete connectivity; (2) problems implementing Formulary & Benefits Standard 1.0 limit complete plan-to-prescriber connectivity; and (3) only 5.0 percent of plan sponsors reported no plan-to-dispenser connectivity.
Recommendations. OIG recommends that CMS ensure that plan sponsors completely implement the plan-to-prescriber and plan-to-dispenser standards. To achieve this, CMS could continue to educate plan sponsors about e-prescribing requirements, clarify e-prescribing standards exemptions, or use corrective action plans and civil monetary penalties to bring plan sponsors into compliance. OIG also recommends that CMS collaborate with plan sponsors, pharmaceutical benefits managers, and standards-development organizations to address batch-processing problems. CMS could also consider pilot-testing a real-time standard that enables plan sponsors to transmit beneficiary-specific formulary and benefits information.
Source: OIG Report, No. OEI-05-08-00320, Oct. 2009
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