Rainmakers Awarded Centers for Medicare and Medicaid Services Part D Formulary Prior Authorization (PA) and Step Therapy (ST) Review Contract
Rainmakers Strategic Solutions LLC (Rainmakers) was awarded the Part D Formulary Prior Authorization (PA) and Step Therapy (ST) Review contract from the Centers for Medicare and Medicaid Services (CMS) to provide technical and clinical support for the Medicare Part D Prescription Drug Benefit.
The addition of a prescription drug benefit to Medicare, via the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, represented a landmark change to the Medicare program and was designed to significantly improve the health care coverage available to millions of Medicare beneficiaries. The drug benefit, which began January 1, 2006, is offered to Medicare beneficiaries through Medicare Advantage drug plans (MA-PDs) and stand-alone prescription drug plans (PDPs).
For this project, Rainmakers will assist CMS in reviewing PA and ST utilization management criteria submitted by the Part D plans to ensure best practices and compliance with Chapter 6 of the Medicare Prescription Drug Benefit Manual. Rainmakers pharmacist reviewers and data analyst will conduct PA and ST criteria reviews and provide CMS with technical assistance and operational support during the annual and monthly review periods. The monthly reviews will also address reviews for PA and ST new and updated criteria.
Rainmakers has extensive knowledge and understanding of the MMA of 2003 and the Medicare Prescription Drug Benefit Manual from many years working on the CMS Part D Formulary and Benefits Review contract. Rainmakers pharmacists conducted over 5 million Part D PA and ST criteria reviews under our prior project term from 2017-2020 and have seamlessly been performing Part D PA and ST criteria reviews since. Our project leadership and pharmacists offer additional depth of understanding from conducting these types of reviews since 2007 under prior contract iterations.