Impacted: Medicare

Please be advised of a Dec. 9, 2024, memo from the Centers for Medicaid & Medicare (CMS) titled Additional Prescription Drug Event Record Reporting Examples for the Implementation of the Inflation Reduction Act for Contract Year 2025.  

The memo includes new rules and reporting requirements for deductible to catastrophic straddle claims for both Enhanced Alternative (EA) and Employer Group Waiver plan (EWGP) types. Included in the memo are examples of plan-specific high dollar claims related to the application of supplemental payer amounts, as well as an example of a Basic Alternative (BA) plan with a reduced deductible. The examples provided illustrate changes needed to system logic to comply with the new requirements effective Jan. 1, 2025.   

Prime Therapeutics (Prime) has initiated a new project to address these prescription drug event (PDE) and adjudication logic changes. We will continue to keep you updated on timing as the project progresses.  

In the meantime, this has been added to Issue Management as IMT 76624 to ensure monitoring is in place for Jan. 1, 2025, in alignment with requirements under Reporting Emergency Part C and D Issues for January 1 through January 3, 2025.  

Please reach out to ClientCommunications@PrimeTherapeutics.com for questions.