1. EGWP & PDE REPORTING Amanda Johnson Division of Payment Reconciliation Medicare Plan Payment Group September 5, 2012 Image of spilled med capsules CMS logo

2. This presentation is not meant to replace existing guidance or forthcoming official guidance. Disclaimer 2

3. To have a discussion with plan sponsors and submitters on Prescription Drug Event (PDE) issues for Employer Group Waiver Plans (EGWPs) Purpose 3

4. Describe current PDE reporting rules for EGWPs offering an Enhanced Alternative plan benefit Describe current PDE reporting rules for EGWPs offering additional coverage through OHI Learning Objectives 4

5. Non Covered Plan Paid Amount (NPP) field is used for enhanced alternative benefits. Field 39 on the PDE Record Layout The amount of plan payment for enhanced alternative benefits. NPP field is excluded from Part D payment reconciliation. PDE Reporting for EGWPs with EA Benefit 5

6. NPP is calculated using the following formula: NPP = GDC – (Patient Pay + CPP + PLRO + Other TrOOP + LICS + Reported Gap Discount) Calculating NPP 6

7. When a plan pays more than what is covered in a given benefit phase under the DS benefit, NPP is positive When the plan and the DS benefit payment is the same, NPP is zero When the plan pays less than what is covered in a given phase under the DS benefit, NPP is negative NPP Values 7

8. Beneficiary purchases $100 drug in Initial Coverage Phase Patient co-pay is $10 NPP = $100 – ($10 + $75) PDE Example 1 Patient Pay Amount CPPNPP $10.00$75.00$15.00 8

9. Patient Liability Reduction Due to Other Payer Amount Field 37 on the PDE Record Layout This field is populated with the dollar amount paid by entities that reduce patient liability/cost but do not count as TrOOP Net change between the original Patient Pay amount and the Patient Pay amount reported by the OHI PDE Reporting When There is OHI 9

10. Determine beneficiary and plan cost-sharing under the Defined Standard benefit for non- Coverage Gap PDEs Determine beneficiary liability under OHI Determine PLRO, which is the difference between original patient pay and OHI patient pay Update patient pay to reflect change in cost- sharing Determine TrOOP Amount General Approach for PDEs with OHI 10

11. Beneficiary purchases $100 drug in Initial Coverage Phase Under OHI beneficiary pays $10 PLRO = $25.00 - $10.00 = $15.00 Patient Pay amount = $10.00 TrOOP amount for this PDE = $10.00 PDE Example 2 Patient Pay AmountCPP $25.00$75.00 11

12. PDE fields PDE Example 2 GDCBPatient Pay Amount CPPPLRO $100.00$10.00$75.00$15.00 $10.00 will count towards TrOOP 12

13. Beneficiary purchases $100 drug in Initial Coverage Phase Under OHI beneficiary pays $30 PLRO = $25.00 - $30.00 = -$5.00 Patient Pay amount = $30.00 TrOOP amount for this PDE = $30.00 PDE Example 3 Patient Pay AmountCPP $25.00$75.00 13

14. PDE fields PDE Example 3 GDCBPatient Pay Amount CPPPLRO $100.00$30.00$75.00-$5.00 $30.00 will count towards TrOOP 14

15. Determine Costs that Fall in the Coverage Gap Determine Discount Eligible Costs – Supplemental benefits apply before determining discount eligible cost – Excludes dispensing fee, and vaccine administration fee Calculate Gap Discount Steps for Coverage Gap PDEs 15

16. Determine beneficiary cost-sharing* – OHI applies after the Gap Discount is applied Calculate Covered and non-Covered Portion of plan paid cost-sharing Update Gross Covered Drug Cost Accumulator and TrOOP Accumulator Steps for Coverage Gap PDEs *Current policy of placing the dispensing fee and vaccine administration fee outside of the Coverage Gap when possible will remain in effect in 2013. 16

17. Questions 17