§ 423.160 - Standards for electronic prescribing.

§ 423.160 Standards for electronic prescribing.

Cross Reference

Link to an amendment published at 89 FR 51263, June 17, 2024.

(a) General rules.

(1) Part D sponsors must establish and maintain an electronic prescription drug program that complies with the applicable standards in paragraph (b) of this section when transmitting, directly or through an intermediary, prescriptions and prescription-related information using electronic media for covered Part D drugs for Part D eligible individuals.

(2) Except as provided in paragraph (a)(3) of this section, prescribers and dispensers that transmit, directly or through an intermediary, prescriptions and prescription-related information using electronic media (including entities transmitting prescriptions or prescription-related information where the prescriber is required by law to issue a prescription for a patient to a non-prescribing provider, such as a nursing facility, that in turn forwards the prescription to a dispenser), must comply with the applicable standards in paragraph (b) of this section when e-prescribing for covered Part D drugs for Part D eligible individuals.

(3) Exemptions.

(i) Until January 1, 2012, entities Entities transmitting prescriptions or prescription-related information by means of computer-generated facsimile are exempt from the requirement to use the NCPDP SCRIPT Standard adopted by this section in transmitting such prescriptions or prescription-related information. After January 1, 2012, entities transmitting prescriptions or prescription-related information must utilize the NCPSP SCRIPT standard must utilize the NCPDP SCRIPT standard, consistent with paragraph (b)(1) of this section, in all instances other than temporary/transient network transmission failures.

(ii) After January 1, 2009, electronic Electronic transmission of prescriptions or prescription-related information by means of computer-generated facsimile is only permitted in instances of temporary/transient transmission failure and communication problems that would preclude the use of the NCPDP SCRIPT Standard standard adopted by this section.

(iii) Entities may use either HL7 messages or the NCPDP SCRIPT Standard standard to transmit prescriptions or prescription-related information internally when the sender and the beneficiary recipient are part of the same legal entity. If an entity sends prescriptions outside the entity (for example, from an HMO to a non-HMO pharmacy), it must use the adopted NCPDP SCRIPT Standard standard or other applicable adopted standards. Any pharmacy within an entity must be able to receive electronic prescription transmittals for Medicare beneficiaries from outside the entity using the adopted NCPDP SCRIPT Standardstandard. This exemption does not supersede any HIPAA requirement that may require the use of a HIPAA transaction standard within an organization.

(

iv) Until November 1, 2014, entities transmitting prescriptions or prescription-related information where the prescriber is required by law to issue a prescription for a patient to a non-prescribing provider (such as a nursing facility) that in turn forwards the prescription to a dispenser are exempt from the requirement to use the NCPDP SCRIPT Standard adopted by this section in transmitting such prescriptions or prescription-related information. As of November 1, 2014, such entities will be required to use the adopted NCPCP SCRIPT standard(s).

(4) In accordance with section 1860D-4(e)(5) of the Act, the standards under this paragraph (b) of this section supersede any State law or regulation that—

(i) Is contrary to the standards or restricts the ability to carry out Part D of Title XVIII of the Act; and

(ii) Pertains to the electronic transmission of medication history and of information on eligibility, benefits, and prescriptions with respect to covered Part D drugs under Part D of Title XVIII of the Act.

(5) Beginning on January 1, 2021, prescribers must, except in the circumstances described in paragraphs (a)(5)(i) through (iii) of this section, conduct prescribing for at least 70 percent of their Schedule II, III, IV, and V controlled substances that are Part D drugs electronically using the applicable standards in paragraph (b) of this section, subject to the exemption in paragraph (a)(3)(iii) of this section. Prescriptions written for a beneficiary in a long-term care facility will not be included in determining compliance until January 1, 2025. Compliance actions against prescribers who do not meet the compliance threshold based on prescriptions written for a beneficiary in a long-term care facility will commence on or after January 1, 2025. Compliance actions against prescribers who do not meet the compliance threshold based on other prescriptions will commence on or after January 1, 2023. Prescribers will be exempt from this requirement in the following situations:

(i) Prescriber issues 100 or fewer controlled substance prescriptions for Part D drugs per calendar year as determined using CMS claims data with dates of service as of December 31st of the current year.

(ii) Prescriber has an address in PECOS in the geographic area of an emergency or disaster declared by a Federal, State, or local government entity. If a prescriber does not have an address in PECOS, prescriber has an address in NPPES in the geographic area of an emergency or disaster declared by a Federal, State, or local government entity. Starting in the 2024 measurement year, CMS will identify which emergencies or disasters qualify for this exception.

(iii) Prescriber has received a CMS-approved waiver because the prescriber is unable to conduct electronic prescribing of controlled substances (EPCS) due to circumstances beyond the prescriber's control.

(b) Standards. —

(1) Entities described in paragraph (a) of this section must comply with the following adopted standards for transactions under this section:

(i) Prior to April 1, 2009, the standards specified in paragraphs (b)(2)(i), (b)(3) and (4), (b)(5)(i), and (b)(6).

(ii) On or after April 1, 2009, to February 7, 2014, the standards specified in paragraphs (b)(2)(ii), (b)(3) and (4), (b)(5)(i) and (b)(6).

(iii) From February 8, 2014, until February 28, 2015, the standards specified in paragraphs (b)(2)(ii), (b)(3) and (4), (b)(5)(ii), and (b)(6).

(iv) From March 1, 2015 until December 31, 2019, the standards specified in paragraphs (b)(2)(iii), (b)(3), (b)(4)(i), (b)(5)(iii), and (b)(6).

(v) On or after January 1, 2020, the standards specified in paragraphs (b)(2)(iv) and (b)(3), (b)(4)(ii), (b)(5)(iii), and (b)(6) of this section.

(2) Prescription.

(i) The National Council for Prescription Drug Programs SCRIPT Standard, Implementation Guide, Version 5, Release 0, (Version 5.0) May 12, 2004 (incorporated by reference in paragraph (c)(1)(iv) of this section), or the National Council for Prescription Drug Programs Prescriber/Pharmacist Interface SCRIPT Standard, Implementation Guide, Version 8, Release 1, (Version 8.1) October 2005 (incorporated by reference in paragraph (c)(1)(i) of this section), to provide for the

Prescriptions, electronic prior authorization, and medication history. The communication of a prescription or prescription-related information

between prescribers and dispensers, for the following:

(A) Get message transaction.

(B) Status response transaction.

(C) Error response transaction.

(D) New prescription transaction.

(E) Prescription change request transaction.

(F) Prescription change response transaction.

(G) Refill prescription request transaction.

(H) Refill prescription response transaction.

(I) Verification transaction.

(J) Password change transaction.

(K) Cancel prescription request transaction.

(L) Cancel prescription response transaction.

(ii) The National Council for Prescription Drug Programs SCRIPT standard, Implementation Guide Version 10.6, approved November 12, 2008 (incorporated by reference in paragraph (c)(1)(v) of this section), or the National Council for Prescription Drug Programs Prescriber/Pharmacist Interface SCRIPT Standard, Implementation Guide, Version 8, Release 1 (Version 8.1), October 2005 (incorporated by reference in paragraph (c)(1)(i) of this section), to provide for the communication of a prescription or prescription-related information between prescribers and dispensers, for the following:

(A) Get message transaction.

(B) Status response transaction.

(C) Error response transaction.

(D) New prescription transaction.

(E) Prescription change request transaction.

(F) Prescription change response transaction.

(G) Refill prescription request transaction.

(H) Refill prescription response transaction.

(I) Verification transaction.

(J) Password change transaction.

(K) Cancel prescription request transaction.

(L) Cancel prescription response transaction.

(M) Fill status notification transaction.

(iii) The National Council for Prescription Drug Programs SCRIPT standard, Implementation Guide Version 10.6 approved November 12, 2008 (incorporated by reference in paragraph (c)(1)(v) of this section), to provide for the communication of a prescription or related prescription related information between prescribers and dispensers for the following:

(A) Get message transaction.

(B) Status response transaction.

(C) Error response transaction.

(D) New prescription transaction.

(E) Prescription change request transaction.

(F) Prescription change response transaction.

(G) Refill prescription request transaction.

(H) Refill prescription response transaction.

(I) Verification transaction.

(J) Password change transaction.

(K) Cancel prescription request transaction.

(L) Cancel prescription response transaction.

(M) Fill status notification.

(iv) The National Council for Prescription Drug Programs SCRIPT standard, Implementation Guide Version 2017071 approved July 28, 2017 (incorporated by reference in paragraph (c)(1)(vii) of this section), to provide for the communication of a prescription or related prescription-related information between prescribers and dispensers for the following:

(

must comply with a standard in 45 CFR 170.205(b) (incorporated by reference, see paragraph (c) of this section) for the following transactions, as applicable to the version of the standard in use:

(i)

(A) GetMessage.

(B) Status.

(C) Error.

(D)

NewRxRequest

RxChangeRequest and RxChangeResponse.

(E)

NewRx

RxRenewalRequest and RxRenewalResponse.

(F)

RxChangeRequest

Resupply.

(G)

RxChangeResponse

Verify.

(H)

RxRenewal Request

CancelRx and CancelRxResponse.

(I)

Resupply

RxFill.

(J)

RxRenewalResponse

DrugAdministration.

(K)

Verify

NewRxRequest.

(L)

CancelRx

NewRx.

(M)

CancelRxResponse

NewRxResponseDenied.

(N)

RxFill

RxTransferInitiationRequest.

(O)

DrugAdministration

RxTransfer.

(P)

NewRxRequest

RxTransferConfirm.

(Q)

NewRxResponseDenied

RxFillIndicatorChange.

(R)

RxTransferRequest

Recertification.

(S)

RxTransferResponse

REMSInitiationRequest and REMSInitiationResponse.

(T)

RxTransferConfirm

REMSRequest and REMSResponse.

(U)

RxFillIndicatorChange

RxHistoryRequest and RxHistoryResponse.

(V)

Recertification

PAInitiationRequest and PAInitiationResponse.

(W)

REMSIinitiationRequest

PARequest and PAResponse.

(X)

REMSIinitiationResponse

PAAppealRequest and PAAppealResponse.

(Y)

REMSRequest

PACancelRequest and PACancelResponse.

(Z)

REMSResponse

PANotification.

(

3) Eligibility. (i) The Accredited Standards Committee X12N 270/271-Health Care Eligibility Benefit Inquiry and Response, Version 5010, April 2008, ASC X12N/005010x279 (incorporated by reference in paragraph (c)(2)(i) of this section), for transmitting eligibility

ii) [Reserved]

(2) Eligibility. Eligibility inquiries and responses between

prescribers and Part D sponsors.

(ii) The National Council for Prescription Drug Programs Telecommunication Standard Specification, Version D, Release 0 (Version D.0), August 2007, and equivalent NCPDP Batch Standard Batch Implementation Guide, Version 1, Release 2 (Version 1.2), January 2006 supporting Telecommunications Standard Implementation Guide, Version D, Release 0 (Version D.0), August 2007, for the NCPDP Data Record in the Detail Data Record (incorporated by reference in paragraph (c)(1)(iii) of this section), for transmitting eligibility inquiries and responses between dispensers and Part D sponsors.

(4) Medication history. Medication history to provide for the communication of Medicare Part D medication history information among Medicare Part D sponsors, prescribers and dispensers:

(i) Until January 1, 2020, Either the National Council for Prescription Drug Programs Prescriber/Pharmacist Interface SCRIPT Standard, Implementation Guide Version 8, Release 1 (Version 8.1), October 2005 (incorporated by reference in paragraph (c)(1)(i) of this section, or the National Council for Prescription Drug Programs SCRIPT Standard, Implementation Guide Version 10.6, approved November 12, 2008 (incorporated by reference in paragraph (c)(1)(v) of this section.

(ii) On or after January 1, 2020, the National Council for Prescription Drug Programs SCRIPT Standard, Implementation Guide Version 2017071, approved July 28, 2017 (incorporated by reference in paragraph (c)(1)(vii) of this section).

(5)

the Part D sponsor and prescribers and between the Part D sponsor and dispensers must comply with 45 CFR 162.1202.

(3) Formulary and benefits. The National Council for Prescription Drug Programs Formulary and Benefits Standard, Implementation Guide, Version

1

3, Release 0 (Version

1

3.0),

October 2005

(incorporated by reference

in

, see paragraph (c)

(1

)

(ii)

of this section)

for transmitting formulary and benefits information between prescribers and Medicare Part D sponsors.(i) Formulary and benefits. Before The National Council for Prescription Drug Programs Formulary and Benefits Standard, Implementation Guide, Version 1, Release 0 (Version 1.0), October 2005 (incorporated by reference in paragraph (c)(1)(ii)

or comply with a standard in 45 CFR 170.205(u) (incorporated by reference, see paragraph (c) of this section) for transmitting formulary and benefits information between prescribers and

Medicare

Part D sponsors.

(ii) Formulary and benefits. On The National Council for Prescription Drug Programs Formulary and Benefits Standard, Implementation Guide, Version 1, Release 0 (Version 1.0), October 2005 (incorporated by reference in paragraph (c)(1)(ii) of this section), or The National Council for Prescription Drug Programs Formulary and Benefits Standard, Implementation Guide, Version 3, Release 0 (Version 3.0), April 2012 (incorporated by reference in paragraph (c)(1)(vi) of this section) for transmitting formulary and benefits

Beginning January 1, 2027, transmission of formulary and benefit information between prescribers and

Medicare

Part D sponsors must comply with a standard in 45 CFR 170.205(

iii) Formulary and benefits. The National Council for Prescription Drug Programs Formulary and Benefits Standard, Implementation Guide, Version 3, Release 0 (Version 3.0), April 2012 (incorporation by reference in

u) (incorporated by reference, see paragraph (c)

(1)(vi)

of this section)

for transmitting formulary and benefits information between prescribers and Medicare Part D sponsors

.

(

6

4) Provider identifier. The National Provider Identifier (NPI), as defined at 45 CFR 162.406, to identify an individual health care provider to Medicare Part D sponsors, prescribers and dispensers, in electronically transmitted prescriptions or prescription-related materials for Medicare Part D covered drugs for Medicare Part D eligible individuals.

(

7

5)Real-time benefit tools.

No later than January 1, 2021,

Part D sponsors must implement one or more electronic real-time benefit tools (RTBT) that are capable of integrating with at least one prescriber's e-Prescribing (eRx) system or electronic health record (EHR) to provide complete, accurate, timely, clinically appropriate, patient-specific formulary and benefit information to the prescriber in real time for assessing coverage under the Part D plan. Such information must include enrollee cost-sharing information, clinically appropriate formulary alternatives, when available, and the formulary status of each drug presented including any utilization management requirements applicable to each alternative drug.

(8) Electronic prior authorization.

(i)

Beginning January 1,

2021

2027, Part D sponsors

and prescribers may use the National Council for Prescription Drug Programs SCRIPT standard, Implementation Guide Version 2017071 approved July 28, 2017 (incorporated by reference in

' RTBT must comply with a standard in 45 CFR 170.205(c) (incorporated by reference, see paragraph (c)

(1)(vii)

of this section)

, to provide for the communication of a prescription or prescription-related information between prescribers and Part D sponsors for the following transactions:

(A) PAInitiationRequest and PAInitiationResponse.

(B) PARequest and PAResponse.

(C) PAAppealRequest and PAAppealResponse.

(D) PACancelRequest and PACancelResponse.

(ii) Beginning January 1, 2022, Part D sponsors and prescribers must use the standard specified in paragraph (b)(8)(i) of this section for the transactions listed in paragraphs (b)(8)(i)(A) through (D) of this section.

(c) Incorporation by reference. The Director of the Federal Register approves, in accordance with

.

(c) Incorporation by reference. The material listed in this paragraph (c) is incorporated by reference into this section with the approval of the Director of the Federal Register under 5 U.S.C. 552(a) and 1 CFR part 51, the . All approved incorporation by reference of certain publications into this section. You may inspect copies of these publications at the headquarters of the (IBR) material is available for inspection at the Centers for Medicare & Medicaid Services (CMS) , and at the National Archives and Records Administration (NARA). Contact CMS at: CMS 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday from 8:30 a.m. to 4 p.m. or at the National Archives and Records Administration (NARA). For more ; phone: [phone] or [phone]; email: [e-mail]. For information on the availability of this material at NARA, call [phone], or go to http://visit www.archives.gov/federal_-register/code_of_federal_regulationscfr/ibr_-locations or email fr.htmlinspection@nara. The publications approved for incorporation by reference and their original sources are as follows:

(1)

gov. The material may be obtained from National Council for Prescription Drug Programs (NCPDP), Incorporated, 9240 E

.

Raintree Drive, Scottsdale, AZ 85260-7518;

Telephone

phone: [phone];

and Facsimile [phone] or http://

email: [e-mail]; website: www.ncpdp.org.

(

i) National Council for Prescription Drug Programs Prescriber/Pharmacist Interface SCRIPT Standard, Implementation Guide, Version 8, Release

1

, October 2005.(ii) The National Council for Prescription Drug Programs

) NCPDP Formulary and

Benefits

Benefit Standard, Implementation Guide, Version

1

3, Release 0

, October 2005.

(

iii) National Council for Prescription Drug Programs Telecommunication Standard Specification, Version D, Release 0 (Version D

Version 3.0),

August 2007 and equivalent National Council for Prescription Drug Programs (NCPDP) Batch Standard Batch Implementation Guide, Version 1, Release 2 (Version 1.2), August 2007 supporting Telecommunication Standard Implementation Guide, Version D, Release 0 (Version D.0) for the NCPDP Data Record in the Detail Data Record.(iv) National Council for Prescription Drug Programs

ANSI-approved January 28, 2011.

(2) NCPDP SCRIPT Standard, Implementation Guide

,

Version

5, Release 0, May 12, 2004, excluding the Prescription Fill Status Notification Transaction (and its three business cases; Prescription Fill Status Notification Transaction—Filled, Prescription Fill Status Notification Transaction—Not Filled, and Prescription Fill Status Notification Transaction—Partial Fill).(v) National Council for Prescription Drug Programs

2017071, ANSI-approved July 28, 2017.

(3) NCPDP SCRIPT Standard, Implementation Guide Version

10.6

2023011, ANSI-approved

November 12

January 17,

2008

2023.

(

vi) The National Council for Prescription Drug Programs Formulary and Benefits

4) NCPDP Real-Time Prescription Benefit Standard, Implementation Guide

,

Version

3, Release 0 (Version 3.0), published April 2012.(vii) National Council for Prescription Drug Programs SCRIPT

13, ANSI-approved May 19, 2022.

(5) NCPDP Formulary and Benefit Standard, Implementation Guide Version

2017071

60,

approved July 28, 2017.

(2) Accredited Standards Committee, 7600 Leesburg Pike, Suite 430, Falls Church, VA 22043; Telephone [phone]; and Facsimile: [phone] or http://www.x12.org.

(i) Accredited Standards Committee (ASC X12 Standards for Electronic Data Interchange Technical Report Type 3—Health Care Eligibility Benefit Inquiry and Response (270/271), April 2008, ASC X12N/005010X279.

(ii) [Reserved]

(Authority: Section 1860D-4(e) of the Social Security Act (42 U.S.C. 1395w-104(e)))

[70 FR 67593, Nov. 7, 2005, as amended at 71 FR 36023, June 23, 2006; 72 FR 66405, Nov. 27, 2007; 73 FR 18941, Apr. 7, 2008; 73 FR 69938, Nov. 19, 2008; 75 FR 38030, July 1, 2010; 77 FR 29030, May 16, 2012; 77 FR 69371, Nov. 16, 2012; 78 FR 74822, Dec. 10, 2013; 83 FR 16743, Apr. 16, 2018; 83 FR 27915, June 15, 2018; 84 FR 23883, May 23, 2019; 85 FR 85037, Dec. 28, 2020; 85 FR 86835, Dec. 31, 2020; 86 FR 65682, Nov. 19, 2021; 87 FR 70231, Nov. 18, 2022; 88 FR 79540, Nov. 16, 2023

ANSI-approved April 12, 2023.

[89 FR 51263, June 17, 2024]