Coverage Gap Discount Program (CGDP) Introduction For Manufacturers October 28, 2010
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1 Coverage Gap Discount Program (CGDP) Introduction For Manufacturers October 28, 2010 Agenda Introduction and Welcome Objectives Quarterly Payment Information Flow TPA Welcome Letter Draft Report Formats
2 Objectives Introduce Third Party Administrator (TPA) Initiate process to establish connectivity between TPA and Manufacturers Review TPA Welcome Letter Review reports exchanged between TPA and Manufacturer 2
3 Coverage Gap Discount Program (CGDP) CGDP reduces cost-sharing for non-lis beneficiaries who purchase applicable drugs in the coverage gap from 100% (in 2010) ~50% (in 2011) ~25%(in 2020) Gap Discount funded by Manufacturer remains constant at about 50% from 2011 forward Gap Discount = 50% of Gap Discount eligible cost Gap Discount eligible cost is cost in the Coverage Gap excluding Supplemental benefits Dispensing fee Vaccine administration fee On graduated basis Part D Sponsor pays increasing share of cost, from 2.5% in 2013 to 25% in 2020 and thereafter 3
4 Point-of-Sale (POS) Information Flow CMS Part D Sponsor PDE Pharmacy Billing Transactions 4
5 PDE is Final Action Summary of Individual Claim PDE summarizes adjudication of an individual claim Unlike other Medicare Programs, Part D Sponsor (not CMS) adjudicates claims following CMS guidance Part D sponsors must retain audit trails linking PDEs to source billing transactions Reporting is based on final action When sponsor adjusts or deletes previously saved record the most recent record submitted is designated as final action record Excludes final action deleted records 5
6 Quarterly Report Information Flow Sponsor advances Gap Discount payment to pharmacy Sponsor sends PDE to CMS CMS compiles quarterly reports with payment information from Gap Discount PDEs received during the quarter TPA sends quarterly reports to Manufacturer and TPA; quarterly reports based on PDEs with Gap Discounts reported during the quarter Detail report Invoice report Within 38 days following report distribution, Manufacturer reimburses Part D sponsor in full for Gap Discount payments sponsor advanced to the pharmacy Manufacturer sends confirmation of payment to TPA TPA informs CMS that payments were made CMS recoups Manufacturer payments from Part D Sponsors 6
7 TPA Roles for Quarterly Reports and Payments Provide customer support to Manufacturer and/or their Third Party Vendor to assist in establishing and maintaining connectivity Distribute Medicare Part D discount information and quarterly invoices to the Manufacturer Process acknowledgement transactions related to invoices from the Manufacturers and Part D sponsors Confirm Payment in Full : Compare Payment Confirmation Report totals to Invoice Report totals; report any discrepancies to CMS Coordinate notice to Manufacturer of Part D Sponsor Electronic Funds Transfer (EFT) information 7
8 TPA Welcome Letter TPA will send Welcome Letter to each Manufacturer Contact person Manufacturer will reply with the following 1. Connectivity options Existing AT&T dedicated circuit and connect direct software (C:D) Existing AT&T Ivans connection and FTP software Internet connection and SFTP software 2. Technical Contact person information 3. Third party vendor information, if applicable With Manufacturer authorization, third party vendors may receive copies of detail and invoice reports TPA will provide additional instructions to authorize data exchange between TPA and third party vendor Return Welcome Letter within 15 days 8
9 TPA Contact Information All customer support will be provided through our existing Customer and Support Center (CSSC) located at Palmetto GBA LLC in Columbia, South Carolina We will offer ongoing support by our dedicated staff through the CSSC Help Line at Hours of operations - Monday through Friday from 8:00am to 7:00pm EST Or send inquiries to our address at: csscoperations@palmettogba.com Web site address 9
10 10
11 Quarterly Payment Reports Overview First step in reporting is to establish connectivity with TPA Three Reports for Quarterly Payment Detail Report Invoice Report Payment Confirmation Report Information to provide a context for establishing connectivity TPA distributes Manufacturer and Part D sponsor versions of reports and resolves questions Report Frequency: Quarterly Source data: PDEs 11
12 Detail Report Developed per request from Manufacturers to give them a basis for reviewing inputs to the invoice Provides row of detail data for each Gap Discount included in the quarterly invoice (Manufacturer Agreement-Exhibit A) Detail reports are updated to incorporate changes in subsequent quarters due to adjustments or deletions Adjustments or deletions may be initiated independently by Part D sponsor or in response to dispute Gap Discount detail records grouped by Labeler Code (first 5 digits of NDC) PDE field names and formats used whenever possible 12
13 Detail Report Record Format: Draft (page one) FIELD NO FIELD NAME POSITIONPICTURE LENGTH DEFINITION / VALUES 1 Record Type Code 1-6 X(6) 6 to be defined 2 Report ID (Year/Quarter) 3 Sequence Number 4 Detail Ref Number 5 Previous Report ID (Year/Quarter) (6) 6 Year/Quarter item was placed on the invoice. Format is: "YYYYQQ" (7) 7 An incrementing batch sequence number that starts at X(20) 20 Randomly Assigned number that uniquely identifies the individual Gap Discount PDE (6) 6 Preceding Year/Quarter that item was placed on the invoice. Format is: "YYYYQQ" 6 Product X(19) 19 First 11 positions are NDC, no spaces or hyphens, followed by 8 ID spaces. Format is:mmmmmddddpp. 7 Prescription Reference No (12) 12 The field length of 12 will be implemented in DDPS on January 1, 2011 in anticipation of the implementation of the NCPDP D.0 standard in Prior to D.O implementation values will be right justified and filled with 5 leading zeroes. Applies to all PDEs submitted January 1, 2011 and after 8 Fill Number (2) 2 Values = Days Supply (3)
14 Detail Report Record Format: Draft (page two) FIELD NO FIELD NAME POSITIONPICTURE LENGTH DEFINITION / VALUES 10 Quantity Dispensed (7)V Number of Units, Grams, Milliliters, other. If compounded item, total of all ingredients will be supplied as Quantity Dispensed 11 Date of (DOS) (8) 8 CCYYMMDD 12 Provider ID X(2) 2 The type of pharmacy provider identifier used in field 12. Qualifier 01 = National Provider Identifier (NPI) 06 = UPIN 07 = NCPDP Provider ID 08 = State License 11 = Federal Tax Number 13 Provider ID X(15) 15 The identifier for the Provider. 14 Reported Gap Discount Previous Amount 15 Reported Gap Discount Current Amount S9(6)V99 8 Reported Gap Discount that was reported on the preceding Detail and Invoice reports S9(6)V99 8 Reported Gap Discount reported this quarter 16 Gap Discount Amount this Period S9(6)V99 8 Calculated as Reported Gap Discount Current Amount minus Reported Gap Discount Previous Amount. Indicates the change in the Gap Discount amount from the amount reported in the preceding Detail and Invoice reports 14
15 Coverage Gap Discount Program Detail Report (Draft) Header Record Manufacturer Header Record Labeler Code Coverage Gap Discount Program Detail Report (Draft) Reported Reported Gap Prescription Gap Gap Discount Provider Discount Discount Amount Current Prev Product Reference Fill Days Quantity Date of ID Previous Current This Ref# Qtr Qtr ID Number # Supply Dispensed Qualifier Provider ID Amount Amount Period /15/ /15/ /01/ /01/ /15/ Trailer Record Labeler Code Header Record Labeler Code /02/ /18/ /12/ Trailer Record Labeler Code Trailer Record Manufacturer
16 Invoice Report Reports quarterly Gap Discount amounts Manufacturers will pay each Part D sponsor Manufacturers pay invoice amount in full within 38 days of report distribution. Note: Payment and dispute are separate activities; payment in full precedes dispute CMS and the TPA will perform thorough data quality review to ensure accurate reporting. To assess report accuracy, Manufacturer may check that Detail Report total equals Invoice Report total; report any discrepancies to TPA 16
17 Invoice Report Record Format: Draft Coverage Gap Discount Program Invoice Report (Draft) Manufacturer Header Record Parent Organization One Header Contract A Header Labeler Code Labeler Code Contract A Trailer 275 Contract B Header Labeler Code Labeler Code Contract B Trailer 425 Parent Organization Trailer 700 Manufacturer Trailer Record
18 Confirmation of Accurate Reporting Detail Report total equals Invoice Report total Header Record Manufacturer Header Record Labeler Code Coverage Gap Discount Program Detail Report (Draft) Reported Manufacturer Header Record Reported Gap Gap Discount Discount Gap Discount Prev Prescription Days Quantity Date of Provider ID Provider Previous Current Amount This Ref# Current Qtr Qtr Product ID Reference Number Fill # Supply Dispensed Parent Organization Qualifier ID One Header Amount Amount Period /15/ /15/ /01/ /01/ /15/ Trailer Record Labeler Code Header Record Labeler Code /02/ /18/ /12/ Trailer Record Labeler Code Coverage Gap Discount Program Invoice Report (Draft) Contract A Header Labeler Code Labeler Code Contract A Trailer 275 Contract B Header Labeler Code Labeler Code Contract B Trailer 425 Parent Organization Trailer 700 Manufacturer Trailer Record Trailer Record Manufacturer
19 Quarter 1 Detail Report Showing Adjustment from Previous Quarter Reported Gap Discount Previous Reported Gap Discount Current Ref# Current Qtr Prev Qtr Product ID Prescription Reference Number Fill # Days Supply Quantity Dispensed Date of Provider ID Qualifier Provider ID Amount Amount Gap Discount Amount This Period /15/ /01/ /01/ Quarter 3 Ref# Current Qtr Prev Qtr Product ID Prescription Reference Number Fill # Days Supply Quantity Dispensed Date of Provider ID Qualifier Provider ID Reported Gap Discount Previous Amount Reported Gap Discount Current Amount Gap Discount Amount This Period /15/ /01/ /01/
20 Confirmation of Payment Report Report design is underway Expect format similar to Invoice Report Timeline: Manufacturer makes payment to Part D sponsor within 38 calendar days of report distribution Manufacturer sends Confirmation of Payment report to TPA 5 days following (by day 43) 20
21 Comments/Questions Please submit comments and questions on the evaluation form. 21
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