CMS-0056-F Pharmacy Standards Compliance Update, CMS-4205-F2 and Readiness Notice

TO: All Pharmacy Providers, Vendors, Prescribers, Clearinghouses and Trading Partners

RE: CMS-0056-F Pharmacy Standards Compliance Update, CMS-4205-F2 and Readiness Notice

Please share this Provider ALERT with your pharmacy software vendor.

The Alabama Medicaid Agency (Medicaid) and Gainwell Technologies are in the process of implementing the federal CMS-0056-F pharmacy standards changes, which adopt updated National Council for Prescription Drug Programs (NCPDP) and related HIPAA transaction standards. These updates are designed to modernize pharmacy data exchange, improve interoperability and support future pharmacy transaction processing requirements. Pharmacies are encouraged to contact their pharmacy software vendors to ensure pharmacy transaction compliance deadlines are met.

Key Standards and Compliance Dates

The following standards will require updates by payers, pharmacies, vendors, prescribers, clearinghouses and trading partners:

· NCPDP Formulary & Benefit (F&B) Standard v60

o Supports electronic exchange of formulary and benefit information used during prescribing.

o Federal compliance date: January 1, 2027

· NCPDP SCRIPT Standard v2023011

o Includes medication history and electronic prescribing enhancements.

o Federal compliance date: January 1, 2028

· HIPAA ASC X12 271 Eligibility Response Updates

o Supports formulary identifiers and pharmacy benefit information exchanges.

o Federal compliance date: February 11, 2028

· NCPDP Telecommunication Standard vF6

o Supports real-time pharmacy claim adjudication and related retail pharmacy transactions.

o Voluntary D.0/F6 dual processing: D.0 transactions will continue to be adjudicated until April 14, 2028. Medicaid will start accepting F6 transactions on August 14, 2027.

o Federal compliance date: April 14, 2028

o D.0 processing ends: April 14, 2028, in accordance with the CMS-0056 Final Rule.

· NCPDP Batch Standard v15

o Supports batch pharmacy claim processing and related transaction exchanges.

o Federal compliance date: April 14, 2028

· NCPDP Batch Subrogation Standard v10

o Supports pharmacy subrogation and financial recovery transactions.

o Federal compliance date: April 14, 2028

All standards above are adopted under the CMS-0056-F HIPAA Administrative Simplification Final Rule.

Impact

These updates may affect:

· Pharmacy claim adjudication and eligibility verification

· Coordination of benefits (COB) processing

· Batch claims and subrogation transactions

· Electronic prescribing and medication history exchanges

· Formulary and benefit transactions

· Trading partner interfaces and vendor-supported pharmacy transactions

Pharmacy providers should work closely with their software vendors, clearinghouses, switch vendors and trading partners to ensure readiness. Medicaid will no longer be able to support D.0 transactions on April 14, 2028, in accordance with the CMS-0056 Final Rule.

Testing

Gainwell plans to conduct vendor and external entity testing from May 5, 2027, through May 25, 2027.

Please email [email protected]if you have any questions.

Next Steps

Updated companion guides, technical specifications, implementation guidance, educational materials and additional testing information will be communicated as they become available. A provider survey will also be forthcoming to gather information related to F6 implementation readiness.

Additional information is available through:

· CMS-0056-F HIPAA Administrative Simplification Final Rule

https://www.federalregister.gov/documents/2024/12/13/2024-29138/administrative-simplification-modifications-of-health-insurance-portability-and-accountability-act

Medicaid appreciates your continued partnership as we work toward implementation of these federally mandated standards.

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