Board of Pharmacy Specialties

Melissa Luechtefeld, Doctor of Pharmacy Candidate Class of 2015 University of Missouri-Kansas City School of Pharmacy at MU

Melissa Luechtefeld, Doctor of Pharmacy Candidate Class of 2015 University of Missouri-Kansas City School of Pharmacy at MU


The Board of Pharmacy Specialties (BPS) was organized in 1976 following the recommendations of the Task Force on Specialties in Pharmacy, a group developed three years prior by the American Pharmacists Association (APhA) in response to changing health care practices in the US. According to, “The overriding concern of BPS is to ensure that the public receives the level of pharmacy services that will improve a patient’s quality of life,” and to achieve this goal, the Board has recognized specialty practice areas.

The available BPS certifications include Ambulatory Care Pharmacy, Critical Care Pharmacy, Oncology Pharmacy, Nuclear Pharmacy, Pediatric Pharmacy, Pharmacotherapy, Nutrition Support Pharmacy, and Psychiatric Pharmacy. Under “News Room” on the BPS website, fact sheets and brochures outlining each specialty can be viewed.

The first specialty, Board Certified Ambulatory Care Pharmacist (BCACP), “addresses the provision of integrated, accessible healthcare services for ambulatory patients in a wide variety of settings, including community pharmacies, clinics and physician offices,” as documented on its fact sheet. As a BCACP, focus will be on the special needs of patients with concurrent illnesses taking multiple drugs at home or with caregiver assistance. Pharmacists will strive to integrate the care of acute illness and exacerbations with chronic disease state management, engaging the patient in health promotion and wellness. By assessing for appropriate treatment, monitoring patient compliance, refilling prescriptions, and providing patient education, sustained partnerships with ambulatory patients will be made. According to the BPS website, 1,659 pharmacists hold the BCACP title as of June 2014.

Board Certified Critical Care Pharmacists work to guarantee the safe and effective use of medications in critically ill patients, as described on the specialty’s fact sheet. In addition to the patients’ primary conditions, their focus is on the specialized pharmacologic or technological interventions the critically ill may need to maintain blood pressure, respiration, nutrition, and other homeostatic functions. As a Critical Care Pharmacist, multifaceted clinical and technological data will be reviewed frequently for patients with life-threatening conditions and complex medications; this information will be used to make reasoned decisions, taking into account the differences in pharmacokinetic and pharmacodynamic parameters between critically ill and non-critically ill patients. The first examination for this specialty will be administered in the fall of 2015.

Oncology pharmacy is centered on the provision of evidence-based, patient-centered medication therapy management for cancer patients. A Board Certified Oncology Pharmacist (BCOP) has the ability to manage adverse events that are both cancer-related and drug-related as well as disease-specific clinical situations arising from the complexity of drug therapies to treat and prevent cancer. The BCOP fact sheet states pharmacists will be “specially trained to recommend, design, implement, monitor, and modify pharmacotherapeutic plans to optimize outcomes… and reduce medication errors” for their patients. The BCOP will work as a part of a multidisciplinary team in hospitals and ambulatory clinics; they will serve as a resource for community pharmacists filling prescriptions for outpatients with malignant disease. As of June 2014, the number of board certified oncology pharmacists is 1,626.

In 1978, nuclear pharmacy was the first specialty approved by BPS according to the online fact sheet. A Board Certified Nuclear Pharmacist (BCNP) has the expertise to prepare and handle highly toxic radiopharmaceuticals. Pharmacists are also involved in quality control, testing, and health and safety issues related to the products; their role allows for minimal error, drug-drug interactions, and patient exposure to radiation. As of 2014, there are 528 Board Certified Nuclear Pharmacists.

Another specialty new for fall 2015 is the BPS Pediatric Pharmacist certification. As described on the fact sheet, providing patient care to those under 18, including alternate dosage forms and specialized drug therapy monitoring, will be the focus. Pharmacists will serve as an advocate for the pediatric population, providing education and promoting health and wellness to advance knowledge and skills in pediatric pharmacy.

The largest specialty certification, with 14,282 certified pharmacists as of June 2014, is Board Certified Pharmacotherapy Specialist (BCPS). As a BCPS, pharmacists work as a part of an interprofessional team to guarantee the “safe, appropriate and economical use of medications… in a variety of settings, including hospitals and health systems,” as described by the online fact sheet. BCPS pharmacists work with physicians to design and/or modify treatment plans, serving as an objective, evidence-based source for therapeutic recommendations and information. In the outpatient setting, they again team with physicians to optimize medication therapy by tracking progress and compliance. Suggestions on diet and lifestyle changes are also made by pharmacists in order to improve health management.

As a Board Certified Nutrition Support Pharmacist (BCNSP), the care of patients receiving specialized nutrition support is addressed. Patients receiving parenteral (IV) or enteral (feeding tube) nutrition are included; pharmacists work to “promote the maintenance of and/or restore optimal nutrition status through design and modification of individualized treatment plans,” as outlined on the online fact sheet. Direct patient care, type of feeding design, dosing of specific nutrients, compatibility issues, clinical monitoring and identification of nutrient deficits, parenteral and enteral feeding formulation preparation, and maintenance of nutritional status during critical transition to outpatient care highlight the main responsibilities of a BCNSP. Only 533 pharmacists hold the BCNSP title as of June 2014.

Per the fact sheet for this specialty, a slightly higher pharmacist population, 805 as of June 2014, hold the BPS Board Certified Psychiatric Pharmacist credential (BCPP), through which care is provided to patients with psychiatric-related illnesses. Expertise is demonstrated when providing care to patients with multi-sided symptoms. Treatment assessment, cost-effective medication regimen design, appropriate dosing, and monitoring of complex medications for potential adverse reactions and interactions, adjusting medications accordingly, encompass a few of the responsibilities of a BCPP. Specialty pharmacists also fill important administrative roles in psychiatric, mental retardation, and substance abuse facilities. A BCPP is a valuable resource for healthcare teams and patients.

Specialty roles allow pharmacists to deliver more complete and complex patient care. With a board certification, BPS emphasizes pharmacists will be confident and prepared to step into evolving pharmacy positions on multidisciplinary teams. As an added bonus, in a competitive employment market, a certification will put the holder one step ahead of contenders. Holding a specialty certification promotes lifelong learning and provides recognition for pharmacists’ expertise by other healthcare professionals, employers, patients and insurers.

Melissa Luechtefeld, Doctor of Pharmacy Candidate Class of 2015
University of Missouri-Kansas City School of Pharmacy at MU



Board of Pharmacy Specialties. 2014. Accessed October 17, 2014.

Enterovirus D-68

Mary Naeger, Pharm.D. candidate, 2015 St. Louis College of Pharmacy

Mary Naeger, Pharm.D. Candidate, 2015
St. Louis College of Pharmacy

The beginning of this year’s “cold and flu season” has brought new attention to and concern for enteroviruses among the U.S. pediatric population. Enterovirus is a genus of RNA viruses that includes twelve distinct Enterovirus and Rhinovirus species. The genus consists of approximately one hundred non-polio enterovirus strains that can cause the common cold, including at least fifty known strains of Enterovirus. The Centers for Disease Control and Prevention (CDC) states that, each year, a mix of Enterovirus strains is noted to cause infection in humans, with a different strain predominating annually. This year, an uncommon strain of Enterovirus known as EV-D68 has been identified as a re-emerging public health concern (Midgley et al., 2014).

EV-D68 was first identified in 1962 among children in California and has rarely been reported in recent years, with only 79 cases reported in the U.S. from 2005 to 2008 (Midgley et al., 2014). EV-D68 is not typically a predominant strain, and experts do not know why it is predominant this year. It has been speculated that children are getting sicker from the EV-D68 strain this year for the very reason that it is uncommon. Children are very unlikely to have encountered the strain before and, therefore, have not built up immunity to it. Pediatric patients with asthma or other respiratory conditions are at a higher risk for developing respiratory symptoms due to EV-D68, because the underlying disease process increases susceptibility to respiratory infections (Owens, 2014).

In 2014, EV-D68 cases were first reported in August in Kansas City, Mo., and Chicago, Ill., with severe respiratory illness noted and several children requiring hospitalization and/or intensive care (Midgley et al., 2014). Among the initial specimens tested by the CDC in August, 19 of 22 specimens collected from the Kansas City hospital and 11 of 14 collected from the Chicago hospital were identified as EV-D68. Of these patients, more than half had a previous history of asthma or wheezing (Midgley et al., 2014). Enteroviruses are not nationally reported, but the CDC does have a voluntary National Enterovirus Surveillance System (Owens, 2014). The implication of the lack of standard national reporting is that the data about cases are not comprehensive and conclusions cannot be accurately drawn.

From mid-August to the end of September, 277 patients in 40 states tested positive for EV-D68, with the majority of these patients being children (Owens, 2014). Although much is unknown about the EV-D68 strain and we do not know if the strain will continue to infect children into the winter months, Enterovirus infections historically tend to peak during late summer/fall and taper out by November (Owens, 2014). The most commonly used test for the virus does not differentiate between Rhinovirus and Enterovirus because of the similarities of chemical makeup (nucleic acid sequence) between many strains of Rhinovirus and Enterovirus (Shaw, Welch, & Milstone, 2014). The CDC has the equipment to perform confirmatory testing to determine the viral strain. Many specimens from throughout the U.S. have been sent to the CDC for testing, and the backlog of specimens that need to be identified has delayed accurate reporting on the virus (Owens, 2014).

After awareness grew about the cases of EV-D68 in late summer, several U.S. hospitals enacted emergency preparedness plans in anticipation of increased transmission of the virus in conjunction with the start of the school year. The emergency preparedness plans have allowed hospitals to mobilize healthcare resources and to communicate with healthcare workers and the community. Communication has enabled education about the virus in an effort to combat the media’s “sensationalization” of the severity of EV-D68 (Shaw, Welch, & Milstone, 2014). Early detection and understanding of the EV-D68 strain has allowed healthcare systems across the country to promote proactive community awareness and to appropriately train and prepare medical staff (Shaw, Welch, & Milstone, 2014). Development of an immunization against EV-D68 has not been possible to date, due largely to the high number of variable strains of Enterovirus species, and antiviral medications have not been shown to be effective against enteroviruses. Treatment for EV-D68 infection consists of symptomatic relief and supportive care—treating fever and pain, providing hydration, stabilizing respiratory status, and providing respiratory support, as appropriate (Owens, 2014).

During the fall and winter months, when children and adults alike tend to get sick with the common cold or influenza, it can be challenging to determine when parents should seek medical treatment for a sick child. Parents should seek medical treatment for their children at a pediatrician’s office or emergency department, as appropriate, if mild cold-like symptoms are noted (sneezing, coughing, runny nose, fever, body aches) along with severe symptoms such as wheezing or difficulty breathing (CDC, 2014). Special attention should be paid to children who have asthma, as they can be predisposed to respiratory illnesses (Siegel, 2014). Children with asthma should receive an annual influenza immunization and should take medications prescribed for asthma as directed (CDC, 2014).

The best way to prevent transmission of EV-D68 is to practice proper infection control and prevention methods (Siegel, 2014). Effective hand washing techniques can help stop the spread of viruses and should be taught to all children. Children and adults should stay home from school or work if illness is suspected, and avoidance of sick contacts should be practiced whenever possible. All people should cover their mouths with a tissue or shirt sleeve when coughing or sneezing and should minimize touching their eyes, nose, and mouth. In addition, surfaces at home, school, and work should be kept clean to minimize transmission (CDC, 2014). Although the influenza immunization will not protect against EV-D68, it will help provide immunity against influenza and should be received by all people over six months old, unless contraindicated.

Mary Naeger, Pharm.D. Candidate, 2015
St. Louis College of Pharmacy



Centers for Disease Control and Prevention (2014, October 14). What parents need to know about enterovirus D68. Retrieved from

Midgley, C.M., Jackson, M.A., Selvarangan, R., Turabelidze, G., Obringer, E., Johnson, D., Giles, B.L., Patel, A., Echols, F., Oberste, M.S., Nix, W.A., Watson, J.T., & Gerber, S.I. (2014). Severe respiratory illness associated with enterovirus d68-Missouri and Illinois, 2014. MMWR Morb Mortal Wkly Rep, 63(36):798-799.

Owens, B. (2014). Rare enterovirus continues to circulate in North America. The Lancet, 384(9950):1250. doi: 10.1016/S0140-6736(14)61753-0

Shaw, J., Welch, T.R., & Milstone, A.M. (2014). The role of syndromic surveillance in directing the publich health response to the enterovirus D68 epidemic. JAMA Pediatr. Published online September 26, 2014. doi: 10.1001/jamapediatrics.2014.2628

Siegal, M. (2014, October 6). 6 things all parents should know about enterovirus D68. Retrieved from

Tan, S.H., Ong, K.C., & Wong, K.T. (2014). Enterovirus 71 can directly infect the brainstem via cranial nerves and infection can be ameliorated by passive immunization. J Neuropathol Exp Neurol, 73(11):999-1008. doi: 10.1097/NEN.0000000000000122

Missouri Board of Pharmacy Meeting: October 16, 2014


The members of the Missouri Board of Pharmacy convened for a meeting on October 16-17 in Columbia. The meeting included open sessions, which the public was free to attend,

Mary Naeger, Pharm.D. Candidate 2015

Mary Naeger, Pharm.D. Candidate 2015, St. Louis College of Pharmacy

and closed sessions, during which the Board conducted private or confidential business. I had the opportunity to attend the Board of Pharmacy meeting on October 16 and was able to witness the workings of the Board and the input from public attendees. Several important issues that affect Missouri pharmacists were discussed during this Board meeting.

Beginning with the pharmacist license renewal period this month, the Board of Pharmacy has reduced renewal fees. This reduction has been a welcome bestowment on licensees across the state, as renewal fees are significantly lower than they have been in recent years. The intern renewal fee has also been reduced this year for the intern license renewal due in December. A reduction in the renewal fee for technicians is in the works and should be established before technician licenses are due to be renewed in the spring. The Board of Pharmacy states that pharmacist renewal is currently at 76 percent. Board members encourage pharmacists who still need to renew their license not to wait until the end of this month. Processing of a license renewal takes several days, and a renewal submitted within the last week of this month is unlikely to be processed before the October 31 deadline. Starting in November, the Board of Pharmacy newsletter will be moved to a new format, including a section about the National Association of Boards of Pharmacy (NABP). New resident and non-resident pharmacy applications have been published and are available at The Board of Pharmacy requests that the old forms no longer be used.

Several topics for discussion included addressing continuing education (CE) for pharmacists and technicians. The Board of Pharmacy has historically accepted CE credits that have been approved by other states and will continue to do so. The Board states that immunization webinars published by the Department of Health and Senior Services (DHSS) are appropriate for CE and provide an effective source of CE relating to immunization to meet the drug administration CE requirement. The Board discussed utilization of NABP’s online CPE Monitor system for pharmacists and technicians to keep track of their continuing education credits. All Missouri licensees will be required to use the CPE Monitor online system to track their continuing education. Historically, the Board of Pharmacy annually audits the CPE (continued pharmacy education) of a random sample of 10% of licensees. Beginning in January 2015, utilization of the online CPE Monitor system will allow the board to audit up to 100% of licensees. Licensees who do not meet the requirements for continuing education will be contacted after this audit. Access to the CPE Monitor website and more information can be found by visiting

The Board discussed the question of shared pharmacy services and how to appropriately label prescriptions that are filled through Class J arrangement shared services. Much discussion was held around this topic, from both the Board and the public audience. The Board members have queried other state Boards of Pharmacy to establish current practices and to evaluate the best method for Missouri. During this discussion, the filling pharmacy was defined as the pharmacy at which the prescription was originally processed and the dispensing pharmacy was defined as the pharmacy that actually fills the prescription. Some states currently include only the name of the filling pharmacy on the prescription label, some states include only the name of the dispensing pharmacy, and other states include both. Some states also require that the patient be notified if his or her prescription(s) will be filled at a location other than the originating pharmacy. The questions of adequate space on labels for additional pharmacy names and the necessity to change Missouri prescription labeling requirements language were addressed. At the close of this topic, it was decided that language will be drafted with options for review, to be determined at a later date. No decision was finalized during the meeting.

Another topic of discussion at the meeting was the question of free or volunteer pharmacy services at charitable organizations. The issue was broached about whether pharmacists providing volunteer services that include the dispensing of medication should be working under a licensed pharmacy and how that pharmacy licensing would be executed, as the type does not fall under any of the current Missouri pharmacy permit class definitions. It was determined that establishments that dispense medications as a free or volunteer service should be registered as pharmacies. Since no current pharmacy class covers this type of pharmacy, the Board discussed adding a new class of pharmacy permits. This discussion led to the question of one-day events, such as health fairs, where medications are distributed. Such events would require the establishment of collaboration with a pharmacy that is licensed to distribute medications and can maintain records adequately. The Board intends to draft language that addresses these two scenarios of charitable pharmacy services. Until this change is established, no further action is needed for pharmacists providing volunteer services.

Mary Naeger, PharmD candidate, 2015
St. Louis College of Pharmacy


Missouri Division of Professional Registration. (2014). Board of Pharmacy. Retrieved from

National Association of Boards of Pharmacy. (2014). CPE Monitoring Service. Retrieved from


Mary Naeger, Pharm.D. Candidate 2015

Public Service Loan Forgiveness Program

Melissa Luechtefeld, Doctor of Pharmacy Candidate Class of 2015 University of Missouri-Kansas City School of Pharmacy at MU

Melissa Luechtefeld, Doctor of Pharmacy Candidate Class of 2015
University of Missouri-Kansas City School of Pharmacy at MU

Do you have one of the following Direct Loan Program loans?1,2

  • Federal Direct Stafford/Ford Loans (Direct Subsidized Loans)
  • Federal Direct Unsubsidized Stafford/Ford Loans (Direct Unsubsidized Loans)
  • Federal Direct PLUS Loans (Direct PLUS Loans)—for parents and graduate or professional students

o   Parents may qualify for forgiveness of the PLUS loan if the parent borrower is employed by a public service organization, regardless of the student’s employer

  • Federal Direct Consolidation Loans (Direct Consolidation Loans)

Do you work for or plan to work full-time for one of the following public service organizations?1,2

  • Serving in a full-time AmeriCorps or Peace Corps position
  • A government organization, including a federal, state, local, or tribal organization, agency, or entity; a public, child, or family service agency; or a tribal college or university
  • A not-for-profit, tax exempt organization under section 501(c)(3) of the Internal Revenue Code
  • A private, not-for-profit organization (that is not a labor union or a partisan political organization) that provides one or more of the following public services:

o   Emergency management

o   Military service

o   Public safety

o   Law enforcement

o   Public interest law services

o   Early childhood education (including licensed or regulated health care, Head Start, and state-funded pre-kindergarten)

o   Public service for individuals with disabilities and the elderly

o   Public health (including nurses, nurse practitioners, nurses in a clinical setting, and full-time professionals engaged in health care practitioner occupations and health care support occupations)

o   Public education

o   Public library services

o   School library or other school-based services

If you answered yes to the two questions above, you are eligible for the Public Service Loan Forgiveness (PSLF) Program. This program was created to encourage individuals to seek employment full-time in public service jobs.

Facts about PSLF1,2

  • Participants will qualify for loan forgiveness:

o   After making 120 qualifying payments after October 1, 2007 on their loans

  • Since 120 payments must be made, the first forgiveness of loan balances will not be granted until October 2017

o   If employed full-time, as defined by employer and at least an annual average of 30 hours per week, not including time spent participating in religious instruction, worship services, or any form of proselytizing, by one of the above public service employers:

  • When making each of the 120 qualifying payments;
  • At the time of application for loan forgiveness; and
  • At the time the remaining balance on the eligible loans is forgiven
  • Part-time employment in more than one qualifying job simultaneously may meet the full-time requirement if a combined average of at least 30 hours per week are fulfilled

o   As long as loans for which forgiveness is requested are not in default

  • The program is available only for loans made and repaid under the Direct Loan Program. Other loans can become eligible for forgiveness if they are consolidated into a Direct Consolidation Loan, and only payments made on the Direct Consolidation Loan will count toward the 120 qualifying payments. The following loans can be consolidated:

o   Federal Family Education Loan (FFEL) Program loans, which include

  • Subsidized Federal Stafford Loans
  • Unsubsidized Federal Stafford Loans
  • Federal PLUS Loans—for parents and graduate or professional students
  • FFEL Consolidation Loans (excluding joint spousal consolidation loans)

o   Federal Perkins Loans

o   Certain Health Professions and Nursing Loans

  • Note: “To consolidate a Federal Perkins Loan or Health Professions or Nursing Loan into a Direct Consolidation Loan, you also must consolidate at least one FFEL Program loan or Direct Loan. If you are unsure about what kind of loans you have, check the U.S. Department of Education’s (ED’s) National Student Loan Data System (NSLDS) at www.nslds.ed.gov2

Specific Loan Repayment Requirements for Forgiveness under PSLF1,2

  • Qualifying payments are those made for the full scheduled installment amount no later than 15 days after the scheduled due date; the 120 required payments do not need to be made consecutively.
  • The 120 required payments must be made under one or more of the following Direct Loan Program

Repayment plans:

o   Income-Based Repayment (IBR) Plan (not available for Direct PLUS Loans made to parents or for Direct Consolidation Loans that repaid Direct or FFEL PLUS Loans made to parents)

o   Pay As You Earn Plan (not available for Direct PLUS Loans made to parents or for Direct Consolidation Loans that repaid Direct or FFEL PLUS Loans made to parents)

o   Income Contingent Repayment (ICR) Plan (not available for Direct PLUS Loans made to parents; however, Direct Consolidation Loans that repaid Direct or FFEL PLUS loans made to parents may be repaid under ICR)

o   10-Year Standard Repayment Plan

o   Any other Direct Loan Program repayment plan; but only payments that are at least equal to the monthly payment amount that would have been required under the 10-Year Standard Repayment Plan may be counted toward the required 120 payments

  • Note: Forgiveness of the remaining balance of a borrower’s eligible loans after the borrower has made 120 qualifying payments on these loans will be granted by the PSLF Program. On average, only borrowers making reduced monthly payments through the IBR, Pay As You Earn, or ICR repayment plans will have a remaining balance after the 120 payments are made on a loan.

How to Apply and Keep Track of Eligibility1,2

  • Complete the Employment Certification for Public Service Loan Forgiveness form, including employer’s certification of employment

o   Monitors progress toward making the 120 qualifying payments necessary to apply for PSLF

o   Allows completion of employer’s certification of employment while still working at the organization or shortly after leaving to confirm qualifying employment and Direct Loan payment eligibility

o   A list by state of eligible employers is not available; use this form to verify employment eligibility, or for a preliminary check, inquire with human resources to see if the organization meets the public service requirements previously listed

  • Submit the Employment Certification for Public Service Loan Forgiveness form annually to FedLoan Servicing, the PSLF servicer, at the address listed in Section 6 of the Employment Certification form

o   Submission can be done less frequently than annually to cover more than one year’s employment or for more than one employer

o   Periodic use of this form is not required, but highly suggested to help keep track of progress toward meeting PSLF eligibility requirements

o   If the form is not submitted periodically, submission of a form for each qualifying employer at the time of application for the forgiveness and when forgiveness is granted will be required

  • After the 120th qualifying payment is made, submit the PSLF application to receive loan forgiveness.

o   This application is currently under development, as the first borrowers will become eligible for forgiveness in October 2017

  • For more details on the PSLF Program, click here.


Melissa Luechtefeld, Doctor of Pharmacy Candidate Class of 2015
University of Missouri-Kansas City School of Pharmacy at MU


  1. Federal Student Aid. Public Service Loan Forgiveness. Accessed October 10, 2014.
  2. Federal Student Aid. Public Service Loan Forgiveness Program. December 2013. Accessed October 10, 2014.


Medicare Part D Late Enrollment Penalty

Melissa Luechtefeld, Pharm.D. Candidate 2015, UMKC School of Pharmacy, Columbia Campus

Melissa Luechtefeld, Pharm.D. Candidate 2015, UMKC School of Pharmacy, Columbia Campus

At the age of 65, patients become eligible for Medicare coverage, and with this eligibility comes pages upon pages of paperwork describing plan options, how to sign up, and rules and restrictions related to coverage. This can be particularly confusing for elderly patients with low health literacy, or those who are not tech savvy or do not have access to electronic versions of plan information to begin with. Vital pieces of information can easily be missed.

For patients turning 65 who are in good general health and take only over-the-counter medications along with one or two prescription medications daily, they may have opted out of Medicare Part D prescription drug coverage when they enrolled in a Medicare Part A and B plan. If the patient’s prescription medications are all on the $4 drug list at their retail pharmacy, their yearly out of pocket costs may have been significantly lower than the premium for a Medicare Part D plan.

What these patients may not have realized is when Part D drug coverage began in 2006, a penalty for late enrollment was initiated as well. This penalty is applicable if at any time after their initial enrollment period ends there is a span of 63 or more days in a row when the patient does not have Medicare Part D or any other creditable prescription drug coverage. The cost of this penalty depends on how long creditable prescription drug coverage was absent, and once calculated, it is then added to the patient’s Medicare Part D premium. For patients who are part of the Extra Help program, the late enrollment penalty does not apply. Extra Help is a Medicare program for those with limited income and resources; this program provides patients with assistance paying drug program costs including premiums, deductibles, and coinsurance.1

Creditable prescription drug coverage refers to coverage from a current or former employer or union that is expected to pay an average of at least as much as Medicare’s standard prescription drug coverage. If the patient has this kind of coverage at the time they become eligible for Medicare, they can keep their coverage without having to pay a penalty upon deciding to switch to Medicare Part D later. Patients already enrolled in Medicare had until the end of their Part D initial enrollment period in 2006 to sign up for a Part D program without incurring a penalty. Plans should update patients yearly in a letter or newsletter informing them whether or not their coverage is considered creditable. Patients should be advised to keep this correspondence because they may need it if they try to join a Medicare drug plan down the road. When patients newly join a Medicare drug plan, they will received a letter if it is believed they went 63 days in a row without drug coverage. This letter will provide them with an opportunity to inform Medicare about their past creditable drug coverage, avoiding penalty fees if criteria are successfully met.1-3

The cost of the penalty is calculated by multiplying 1 percent of the “national base beneficiary premium,” or the average of all Part D plans nationwide in any given year ($32.42 in 2014 and $33.13 in 2015), by the number of full, uncovered months the patient was eligible but did not join a Medicare Prescription Drug Plan or did not have creditable coverage. After rounding to the nearest $0.10, the penalty is added t­­­o the patient’s monthly premium. After joining a Part D plan, the plan will tell the patient if they owe a penalty and what their premium will be. Patients will pay this premium for as long as they have a Medicare drug plan.1-3

For patients who do not agree with their late enrollment penalty, an appeal process exists. A reconsideration request form will be sent to the patient by their Medicare drug plan. Proof that supports their case, such as information about previous creditable prescription drug coverage, can be submitted to ratify the appeal.

It is impossible to predict exactly when taking out prescription drug coverage will be more cost-effective for patients over the age of 65 versus paying cash for generic medications, as each patient’s healthcare needs are unique. Nevertheless, it is important to consider the longer patients wait to enroll in a prescription plan after they become eligible for Medicare, the higher the penalty, as the national base beneficiary premium is trending upward each year.

Pharmacist awareness of the late enrollment penalty is beneficial because retail pharmacists who see patients over the age of 65 paying cash for their monthly medications have the perfect opportunity to make an intervention. Oftentimes these patients will be asking for price-matching and closely watching how much they are charged each month. Pharmacists can ask these patients about their healthcare coverage, specifically if they have Medicare Part A and B, and then they can educate these patients on prescription coverage options, explain the late enrollment penalty, and direct patients to for more information on ways to avoid penalties and maximize the use of their money. Affordable medication leads to increased adherence, improved chronic disease state management, a healthier patient population, and an opportunity for pharmacists to achieve their goal of providing optimal patient-centered care.

Melissa Luechtefeld, Doctor of Pharmacy Candidate Class of 2015
University of Missouri-Kansas City School of Pharmacy at MU


  1. Centers for Medicare & Medicaid Services. What’s the Part D late enrollment penalty? Accessed October 2, 2014.
  2. Centers for Medicare & Medicaid Services. The Part D Late Enrollment Penalty. January 1, 2014. Accessed October 2, 2014.
  3. Barry P. (2008). Paying for the Part D Late Penalty. AARP Bulletin. Retrieved from