The Medicare program integrity regulations set by the Centers for Medicare & Medicaid Services (CMS) previously required prescribers to either enroll in Medicare Part D or validly opt out of Medicare. The intention of the regulation is to fight fraud and abuse by illegitimate providers but it seems like another way to give pharmacists the short end of the stick. Patients often look at and rely on their pharmacists, especially independent pharmacists, to be their providers. However, while some states consider pharmacists to be providers, the federal law does not.


This regulation requires PBMs to deny claims for Part D drugs that are not prescribed by a "physician" or "eligible professional" who has enrolled in or opted out of Medicare. The definition of eligible professional is determined on a list provided by CMS and currently does not include pharmacists. Pharmacies get their lunch money stolen enough by the bullies of PBMs and provider status could be another way to gain income.

In independent pharmacies especially, patients often look at and rely on their pharmacists as providers. However, although some states, such as California, Ohio and Wisconsin, consider pharmacists providers, currently the federal law does not. It's like the state gives pharmacists dessert but the federal law says they can't eat it. CMS is taking steps to fix this and has amended Part D regulations to permit coverage of prescriptions provided by "other eligible prescribers".

The value of being deemed an eligible professional is the availability of different types of health care models. This ultimately brings together the various health care professionals to create a collaborative approach to care. As a result, Medicare patients can receive the care they deserve.