US · guidance
CMS Pub. 100-18, ch. 14, § 50.14.5
Re-adjudication versus Pharmacy Reprocessing
If the total payment to the pharmacy for a claim was correct, but the sponsor subsequently
determines that an adjustment is required that does not affect the total payment and does
alter the sponsor-beneficiary liability split, the sponsor must re - adjudicate the claim within
its own system without involving the pharmacy. This is most likely to occur when the
sponsor corrects low-income beneficiary cost-sharing subsidy levels.
Part D sponsors are encouraged to avoid pharmacy reprocessing, but CMS recognizes that
reversals may be appropriate under certain circumstances. Sponsor requests for pharmacy
reprocessing should generally be limited to those situations where the total payment to the
pharmacy changes (e.g., when there is a pricing error). Sponsors are responsible for
reimbursing or collecting amounts from beneficiaries that result from the reprocessing of
these claims and should not transfer this responsibility to pharmacies.
History
(Rev. 17, Issued: 08 -23-13, Effective Date: 06-07-10, Imple mentation Date : 01-01-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-09-17
- Edition
- iom-2026-09-17
- Content hash
d6fc6168c324823fd8af80fb1a09d59b34959417b5e9c0f7e1f19cde97332686
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