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.