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5010/NCPDP D.0 Overview for Pharmacies

As of January 1, 2012, the National Council for Prescription Drug Programs (NCPDP) changed the standard way pharmacy claims must be transmitted to Aetna.  Telecommunications Standard Version D.0 is an updated version of the Health Insurance Portability and Accountability Act (HIPAA) standard for pharmacy claims transactions. It is an online, real-time conversation of a request from the pharmacy to the health plan AND a response from the health plan to the pharmacy.

NCPDP is the pharmacy component of the larger industry 5010 upgrade. HIPAA X12 Version 5010 is a new set of standards that regulate the electronic transmission of specific healthcare transactions, including eligibility, claim status, referrals, claims, and remittances.

Covered entities, including pharmacies, were required to conform to HIPAA 5010 standards and upgrade to NCPDP D.0 in order to support current pharmacy service transactions.

Due to Aetna’s strategic pharmacy agreement with CVS Caremark to perform certain pharmacy benefit management services on Aetna’s behalf, Aetna worked in collaboration with CVS Caremark to ensure a smooth transition to NCPDP D.0.

Important Dates:

  • January 1, 2011, Aetna, in collaboration with CVS Caremark, began external testing to ensure pharmacies within our network could send and receive compliant transactions.
  • Until December 31, 2011, the final rule allowed transactions to use either the previous version 4010A1, or the new version 5010.
  • On April 11, 2012, Aetna discontinued use of the previous ASC X12 version 4010A1
  • June 30, 2012 is the current extension that the Centers for Medicare and Medicaid Services (CMS) granted to the enforcement period of the D.0 standard, granting payers the option to accept the older 5.1 transactions until this date.

Pharmacist-directed Frequently Asked Questions