AIS Newsletter Offers Advice for Dealing With CMS’s Increased Attention to Pharmaceutical Access Under Medicare Part D

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With 12 civil monetary penalties issued in the first 100 days of 2015, the April 23 issue of Atlantic Information Services’s Medicare Advantage News examines CMS’s increased enforcement of pharmaceutical access rules.

In the first 100 days of 2015, the Centers for Medicare & Medicaid Services (CMS) have issued 12 civil monetary penalties (CMPs) against Medicare Part D plans related to pharmaceutical access — including a $1 million fine against Aetna, Inc., the largest thus far — compared with only one CMP issued in the first three months of 2014, according to Atlantic Information Services, Inc.’s (AIS) Medicare Advantage News (MAN). The April 23 issue of MAN examines this trend, including advice from industry consultants on how to comply with CMS’s pharmaceutical access rules. The 12 fines so far in 2015 put CMPs related to Medicare drug access on pace for a “record year,” John Gorman, executive chairman of Gorman Health Group, LLC, tells the newsletter.

The reasons for CMS’s increased focus on pharmaceutical access are numerous, consultants tell MAN, including a best-practices memo CMS issued on the subject and the ease in which CMS can achieve change in Medicare plan practices via these crackdowns. Also, it’s clear that not having access to pharmaceuticals can lead to beneficiary harm. In fact, the agency has developed algorithms to help it measure the impact on beneficiaries and make the case for penalties.

Consultants tell MAN that Part D plans need to work closer with their pharmacy benefit managers (PBMs). PBMs often “have all kinds of system edits embedded that violate CMS rules,” Gorman says. Steve Arbaugh, CEO of ATTAC Consulting, says plans should work with PBMs to accommodate the necessary changes and to monitor drug-claim rejections on a daily basis. Arbaugh advises plans to use specific reasons for denial, offer possible alternative drugs and avoid using boilerplate language.

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About Medicare Advantage News
Medicare Advantage News is the health care industry’s #1 source of timely news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in this hotly contested area of health insurance. Published biweekly since 1994 (when it was Medicare+Choice), the newsletter exists to help plans boost revenues, increase enrollees, cut costs and improve outcomes in Medicare Advantage and Medicaid managed care. Visit for more information.

About AIS    
Atlantic Information Services, Inc. (AIS) is a publishing and information company that has been serving the health care industry for more than 25 years. It develops highly targeted news, data and strategic information for managers in hospitals, health plans, medical group practices, pharmaceutical companies and other health care organizations. AIS products include print and electronic newsletters, websites, looseleafs, books, strategic reports, databases, webinars and conferences. Learn more at

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Atlantic Information Services
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