Medicare Part D Pharmacy Notice

Please visit the CMS web site to obtain the Model Pharmacy Notice entitled, "Medicare Prescription Drug Coverage and Your Rights" CMS–10147. Once there, you will need to navigate to Sept. 30th listings. This standard notice, CMS–10147, advises enrollees to contact their Medicare Part D Plans to obtain coverage determination or ask for a formulary exception if the enrollee disagrees with the information relayed by the Pharmacist (CMS Requirement 423.562). All participating pharmacies in our Medicare Part D Program must either post this notice in a conspicuous area or hand the notice to Cigna members.

Claim processing information PDP BIN AND PCN:

All Cigna Medicare Rx (PDP) claims for PDP members should be submitted under BIN 012353 and PCN 03490000.

Claim processing information:

The member ID is alpha–numeric with a maximum of 9 characters and a two digit suffix code (usually 01).

Claim processing information for Part B vs. Part D drugs:

Please remind your staff to check the free text message fields for additional processing information.

For the upcoming plan year, Part B vs. D coverage determinations will be managed as follows:

1. When claims for drugs that should be covered under Medicare Part B benefit are submitted, they will be rejected with error code 221 "Part B Only."
2. Drugs that require further review to determine coverage eligibility under Part B vs. Part D will be rejected with error code 195 "PA Required – Determine B or D." Certain drugs that will reject with error code 195 may require the pharmacist to contact the Cigna Pharmacy Service Center for further review. For other drugs, that are more commonly used for Part D eligible indications, in addition to error code 195, a PAC code will be provided in the free form text field. Pharmacists should carefully review the free form text message and assess eligibility for Part D coverage. When deemed eligible, the rejected claims should be resubmitted using the provided PAC code for payment under the Medicare Part D benefit.

In all situations where a drug should be processed under Medicare Part D Prior Authorization Code (PAC) 34910 should be used pending pharmacy review that such drug is Part D eligible. The PAC 34910 applies to all pharmacies and will only work in situations where a PAC code has been requested in the requirements to be returned to the pharmacy to allow the submission of the drug as eligible for coverage under Part D.

Claim processing information – Patient Location Code:

Please enter the appropriate Patient Residence and Place of Service for each claim.

Incorrect patient location code submissions may result in "Pharmacy not in network" denials.

Retail Pharmacies:

Please enter the appropriate Patient Location Code for each claim.
Incorrect patient location code submissions may result in "Pharmacy not in network" denials.
ALF as Retail: Patient Residence = 04 + Place of Service = 01 + Pharmacy Service Type Not = 03 + "Treat ALF as LTC Flag" = N Processed as Indicator Value = AR

LTC Pharmacies:

LTC: Patient Residence = 03 or 09 + Place of Service = 01 + CMS Part D Qlfd Facility = Y or N + Facility Segment Present Processed as Indicator Value = _L
(Please note, there is a space before the "L")

ALF as LTC: Patient Residence = 04 + Place of Service = 01 + Pharmacy Service Type Not = 03 + "Treat ALF as LTC Flag" = Y
Processed as Indicator Value = AL

Home Infusion

Home Infusion at home claims can only be submitted by Home Infusion pharmacies with:

At Home: Patient Residence = 01 + Place of Service = 01 + Pharmacy Service Type = 03 Processed As Indicator Value = HH

At ALF: Patient Residence = 04 + Place of Service = 01 + Pharmacy Service Type = 03 Processed As Indicator Value = HA

Claim processing information standard benefit exclusions:

Standard Benefit Exclusions

Drugs excluded under Medicare Part D:

• Agents for Anorexia, Weight Loss, or Weight Gain
• Agents used to promote fertility
• Agents used for cosmetic purposes or hair growth
• Agents used for the symptomatic relief of cough and cold
• Prescription vitamins and mineral products; except prenatal vitamins and fluoride preparations
• Nonprescription drugs
• "Less than effective" Medicaid drugs
• Barbiturates
• Benzodiazepines