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Network Pharmacy Provider Fraud, Waste and Abuse (FWA) and General Compliance Training Requirements

The Centers for Medicare & Medicaid Services (CMS) mandates that plan sponsors administering a Medicare Advantage program or Medicare Part D prescription drug plan must implement an effective compliance program that meets the regulatory requirements set forth in 42 C.F.R. §422.503(b)(4)(vi) and 42 C.F.R. §423.504(b)(4)(vi) which includes policies and procedures for preventing fraud, waste and abuse or conflicts of interest as well as training and education on applicable Medicare Part D laws, rules, regulations and CMS guidance. In addition, CMS requires Plan Sponsors to ensure that its First-tier, Down-stream and Related (FDR) entities complete an annual Fraud, Waste and Abuse (FWA) and General Compliance Training. In addition, FDRs are required to monitor federal exclusions lists on a monthly basis, as well as annually distribute Code (or Standards) of Conduct information. As a “Network Pharmacy Provider,” you are considered a FDR. On behalf of our Plan Sponsors, we are providing this training to all of our Network Pharmacy Providers.

CastiaRx, on behalf of its Plan Sponsors, will utilizes the Centers for Medicare & Medicaid Services (CMS) standardized Medicare Parts C & D Fraud, Waste and Abuse (FWA) and General Compliance training module. This training module satisfies the regulatory requirement for effective training and education (42 CFR 422.503(b)(4)(vi)(C) and 423.504(b)(4)(vi)(C)) and is located at the following site:

Please distribute the training information to each of your pharmacy staff working with Medicare, Medicaid, Medicare-Medicaid and/or any other government business.

In addition, Organizations contracted to administer federal and state health care programs are prohibited from hiring, continuing to employ, contract, make payments to persons/entities previously excluded/debarred from participation or procurement with federal and/or state health care programs. Network Pharmacy Providers are required to monitor exclusion lists maintained by the Office of Inspector General (OIG) U.S. Department of Health & Human Services (HHS) and U.S. General Services Administration (GSA) System for Award Management (SAM) prior to hire/contracting and monthly thereafter for its current employees/contractors, health professionals or subcontracted entities.

This information is available at the following sites:

CMS requires records demonstrating compliance with these requirements be maintained for ten (10) years. This includes all individuals trained be listed along with the date the FWA and General Compliance Training information is provided/completed, as well as the date of the Office of Inspector General's (OIG) - U.S. Department of Health & Human Services (HHS)/General Services Administration (GSA) monitoring review.

Additional reference materials include the Prescription Drug Benefit Manual (Chapter 9 – Compliance Program Guidelines) & Medicare Managed Care Manual (Chapter 21 – Compliance Program Guidelines). Click Here to review.

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