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Empire Justice Joins the NYS Consumer Coalition on Part D to Highlight the Continuing Need for the EPIC and Medicaid Wraps

May 3, 2010



Don’t End Safety Net “Wrap-around” Coverage in EPIC and Medicaid:
Part D Plans Still Create Barriers to Drug Access

Part D plans continue to improperly deny medically necessary prescription drug claims.

  • In March 2010, CMS terminated a national Part D plan (operating in NYS), for impeding access to medically necessary drugs.

On March 9, 2010, CMS terminated its Medicare Part D contract with the Fox Insurance Company Drug Plan.  CMS found “significant deficiencies” that “jeopardized the health and safety of Fox enrollees.” [1]  CMS found that Fox’s imposition of inappropriate prior authorization and step therapy requirements resulted in thousands of rejected claims, impeding access to medically necessary drugs. These requirements impacted individuals with HIV/AIDS, cancer, and seizure disorders, resulting serious health consequences. CMS’s investigation also found a litany of other contractual violations that impacted beneficiary access to prescriptions. Fox continued to reject claims after CMS imposed sanctions, resulting in termination in March, 2010. [2]    

  • In April 2010, CMS sanctioned a national Medicare Advantage and Part D plan (operating in NYS) for impeding access to medically necessary drugs.

On April 5, 2010, CMS sanctioned Aetna Life Insurance Company for improperly rejecting prescription drug claims to thousands of beneficiaries.  CMS found that Aetna imposed inappropriate prior authorization and step therapy requirements, and that Aetna had failed to provide transitional prescription refills between 2009 and 2010.  Aetna was also cited for substantial violations in their processing of Part D-related appeals. [3]  

  • There have been numerous other Part D plan sanctions in recent years.

Analysis of CMS enforcement actions reveals that ten organizations have been subjected to suspensions of enrollment activity for contractual violations affecting beneficiary access to benefits since Part D began in 2006.  Seven of these actions occurred in 2009-2010. [4] 

As these recent CMS actions illustrate, Part D plans continue to deny coverage of medically necessary prescription drugs to Medicare beneficiaries.  In New York, Medicaid and EPIC must continue to provide a safety net to enrollees who would otherwise be seriously harmed by the wrongful denial of prescription drug claims.  

End Notes
 [1] "Medicare Ends Contract with Fox Insurance Company Drug Plan” CMS Press Release, March 9, 2010,  Accessed April 23, 2010. 
 [2] "Notice of Immediate Termination of Prescription Drug Plan Contract Number S5557” CMS Letter, March 9, 2010. Accessed April 23, 2010. 
 [3] “Notice of Intent to Impose Intermediate Sanctions for All Medicare Advantage/Prescription Drug Contracts and All Standalone Prescription Drug Contracts.” CMS Letter, April 5, 2010. Accessed April 23, 2010. 
 [4] “Enforcement Actions Against Medicare Advantage Organizations and Prescription Drug Sponsors, January 2006-April 2010."  Accessed April 23, 2010.