Part D Pharmacy Directors and Formulary Administrators, Rebellis is ready to assist you with your 2027 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).

Comprehensive testing means validating claims adjudication across all three Part D benefit phases — and, for MAPD plans, confirming Part C benefit accuracy against the Evidence of Coverage — while also verifying that Prescription Drug Event (PDE) reporting will hold up before the first real claim is ever submitted. It also means focusing on where plans most commonly stumble: manufacturer discount and insulin pricing calculations under the Inflation Reduction Act, ACIP-recommended vaccine coverage, formulary administration, and Transition of Care rules for new and existing members.

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, 2027 go-live. Post go-live rejected claims review and appropriate member outreach complete the circle of Part D claims monitoring and oversight.

CMS continues to sharpen its focus on claims accuracy — through Program Audits, Financial Audits, Timeliness Monitoring, and PDE Self-Audits alike. 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, and findings there contribute to overall audit risk, potential civil monetary penalties, and potential plan sanction. But compliance is only half the story — get the benefit set up right, and members receive exactly what they were promised, which is where real trust is built.

How Rebellis can help

Our Rebellis pharmacy experts, with a combined 100+ years in Medicare Part D experience, build customized test cases around your health plan’s specific benefits and cost shares and deliver executive-level summaries that pinpoint exactly what failed and why. We will ensure your pharmacy benefit manager (PBM) is processing claims consistent with your CMS-approved prescription drug benefit.

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