Home Infusion Drugs. The following provisions shall only apply to Provider if Provider dispenses to a Medicare Member home infusion drugs that are covered under Medicare Part D and the Medicare Member has MA-PD coverage offered by Company (“Home Infusion Drug”):
(1) With respect to Home Infusion Drugs, Company will pay clean claims (as defined in 42 C.F.R. § 423.520(b)) submitted by Provider on behalf of Medicare Members within 14 days for electronic claims and within 30 days for claims submitted otherwise. 42 C.F.R. § 423.505(i)(3)(vi).
(2) Home Infusion Drugs will be reimbursed (as applicable) in accordance with a fee schedule, or the third-party pricing source (e.g., Medi-Span) otherwise agreed upon as set forth in this Agreement or Provider’s agreement with Company’s Pharmacy Benefit Manager (“PBM”). 42 C.F.R. § 423.505(i)(3)(viii)(B).
(3) If a prescription drug pricing standard is used for reimbursement of Home Infusion Drugs, updates to such a standard will occur not less frequently than once every 7 days beginning with an initial update on January 1 of each year, to accurately reflect the market price of acquiring the Home Infusion Drug. 42 CFR § 423.505(i)(3)(viii)(A).
(4) In accordance 42 C.F.R.§ 423.120(c)(3), Provider agrees to submit claims for Home Infusion Drugs to Company or its PBM whenever the Medicare Member’s ID card is presented or is on file at the Provider, unless the Medicare Member expressly requests that the claim not be submitted to Company or its PBM.
(5) Provider must submit claims for Home Infusion Drugs in real time by means of point of service claims adjudication systems in compliance with CMS standards. 42 C.F.R. § 423.505(b)(17).
(6) Provider must provide Medicare Members with access to the negotiated prices (as defined in 42 C.F.R. § 423.100) for Home Infusion Drugs to Members. 42 C.F.R. § 423.104(g)(1).
(7) Provider must charge/apply the correct cost-sharing amount to the Medicare Member for Home Infusion Drugs. 42 C.F.R. § 423.104.
(8) At the time of purchase by a Medicare Member, Provider must inform the Medicare Member of any differential between the price of the Home Infusion Drug being dispensed and the price of the lowest priced generic version of that Home Infusion Drug available from Provider, unless the Home Infusion Drug being dispensed is the lowest priced generic version of that Home Infusion Drug. 42 C.F.R. § 423.132.
(9) Provider agrees to ensure that the professional services and ancillary supplies necessary for Home Infusion D...
Home Infusion Drugs. If Provider dispenses home infusion drugs that are covered under Medicare Part D to a MMP Member and such MMP Member has MA-PD coverage offered by Company (“Home Infusion Drug”) then Provider agrees that the home infusion drugs section in the Provider Manual shall, as required by Applicable Law, be considered a part of this Agreement.
