Medicare Part D Claim Processing

Medicare Part D Standardized Pharmacy Notice and Instructions
Beginning in the 2012 plan year, this version of the pharmacy notice must be provided to Part D enrollees when a prescription cannot be covered ("filled") under the Medicare Part D benefit at the point-of-sale (POS).  The regulation requires distribution of this written notice as of January 1, 2012. 

          Standardized Pharmacy Notice

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.

4Rx Unique BIN/PCN accuracy:
Pharmacies are required to enter the bank identification number (BIN)/processor code number (PCN) and member ID that are unique to the member's Part D enrollment.  You should submit the information as it appears on the identification card to avoid point-of-service rejection. 

Member ID information:
The member ID is alpha-numeric with a maximum of 9 characters and a two digit person code (usually 01).  In D.0, when entering the member id number, the person code on the member's ID card must be submitted as part of the member ID submitted in the cardholder ID field (302-C2).  In total, 11 characters should be submitted in the cardholder ID field.  When inputting the 11-digits for the cardholder ID, DO NOT include the space located between the member ID and the person code.

Claim processing information for Part B vs. Part D drugs:
Please reiterate to 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:

• 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".
• 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. Pharmacist 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.

In D.0, Patient Residence codes have replaced Patient Location code; please refer to the below grid for crosswalking information: 

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