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Part D Benefit Administration Testing (BAT)


Part D Pharmacy Directors and Formulary administrators, Rebellis is ready to assist you

with your 2023 BAT testing!


Benefit administration testing continues to be a valuable tool to validate the accuracy of

your Medicare Part D pharmacy claims benefit. Part D sponsors are responsible for

ensuring their Part D prescription drug coverage is adjudicating consistent with their

approved plan design. Benefit administration testing ensures your health plan’s

formulary is processing formulary medications accurately and applying correct cost-

sharing. Additionally, benefit testing ensures that utilization management edits are firing

appropriately, including non-formulary, prior authorization (PA), quantity limits (QL), and

step therapy (ST).


The Centers for Medicare and Medicaid Services (CMS) analyzes the accuracy of the

formulary and plan benefit administration through the Cost Sharing Administration

Analysis (CSAA). This includes evaluating appropriate cost sharing for Part D drugs

consistent with the approved Part D plan. Per the July 22, 2022, HPMS Memo Contract

Year (CY) 2020 Cost Sharing Administration Analysis, CMS intends to complete an

analysis of Part D claims in late Fall 2022.


As a Plan Sponsor, it is CMS’ expectation that you understand and manage the

oversight of your Part D benefit to ensure timely access to formulary medications and

appropriate application of the cost share. To accomplish this, it is important to perform

annual comprehensive benefit administration testing of the formulary files, system edits

and cost-sharing for all payment levels prior to January 1 go-live. Post go-live rejected

claims review and appropriate member outreach complete the circle of Part D claims

monitoring and oversight.


In the event your MAPD health plan is notified of a Compliance Program Audit, CMS will

determine if the plan is properly administering its Part D benefit through the Formulary

Administration module. Findings from the Formulary Administration audit contribute to

overall audit risk, potential civil monetary penalties and potential plan sanction.


Our Rebellis pharmacy experts, with a combined 100+ years in Medicare Part D

experience, can create a plan for your health plan’s 2023 comprehensive benefit

administration testing. We will ensure your pharmacy benefit manager (PBM) is

processing claims consistent with your CMS approved prescription drug benefit.


To get started, contact us here.

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