The Center for Medicare and Medicaid Services (CMS) has many rules and regulations regarding the way that Health Plans manage their Part D services. It’s important to maintain oversight of these functions – especially those that are delegated to a third party. Health Plan Coverage Determinations and Redeterminations have a direct effect on members and CMS expects that every decision meets requirements and prevents harm to the member. Pharmacy Benefit Manager (PBM) oversight of this function is crucial to maintaining compliance.

Per CMS, a Coverage Determination is “any decision made by the Part D plan sponsor regarding:

  • Receipt of, or payment for, a prescription drug that an enrollee believes may be covered
  • A tiering or formulary exception request
  • The amount that the plan sponsor requires an enrollee to pay for a Part D prescription drug and the enrollee disagrees with the plan sponsor
  • A limit on the quantity (or dose) of a requested drug and the enrollee disagrees with the requirement or dosage limitation
  • A requirement that an enrollee try another drug before the plan sponsor will pay for the requested drug and the enrollee disagrees with the requirement
  • A decision whether an enrollee has, or has not, satisfied a prior authorization or other utilization management requirement.”


PillarRx offers Coverage Determination and Redetermination Oversight services to review these plan sponsor decisions (often delegated to a PBM) and ensure that they are meeting CMS requirements. CMS requires that decisions be made timely (with very specific parameters), that the clinical decision-making process is sound, and that communication to the member (enrollee) is accurate, comprehensive, and understandable. As part of oversight services, PillarRx reviews a sample of determinations every month based on these specific requirements. We will discuss any discrepancies with the PBM to confirm that processes be updated, or employees receive training.