September 29, 2014


Pharmaceutical Care Management Association (PCMA) President and CEO Mark Merritt today outlined policy solutions that could reduce prescription fraud and abuse in Medicare Part D at a Capitol Hill briefing, “Prescription Opioid Abuse: Fighting Back on Many Fronts,” sponsored by the Alliance for Health Reform and PCMA.

The briefing featured several government and industry experts discussing ways to combat prescription drug abuse and fraud. The Centers for Disease Control and Prevention has labeled the issue a national epidemic that each year costs tens of thousands of lives and billions of dollars.

“There are common sense solutions to prescription drug abuse that Congress can act on immediately,” said PCMA President and CEO Mark Merritt. “The key is to prevent the abuser from obtaining inappropriate controlled substances at the drugstore counter. This battle must be won at the pharmacy counter.”

The creation of “Safe Pharmacies,” or a “Lock-In” program in Medicare Part D for controlled substances allows Part D plans and beneficiaries to choose a pharmacy that dispenses controlled substances. The policy maintains beneficiary access to needed medications, but prevents “drugstore shopping.”

A recent report by the Health and Human Services Office of Inspector General, “Part D Beneficiaries with Questionable Utilization Patterns for HIV Drugs,” also called for a pharmacy “Lock-In” program in Part D to help decrease prescription drug abuse. Currently, 46 state Medicaid agencies operate “Lock-In” programs, and 49 states have enacted prescription drug monitoring legislation.

In addition, Part D Plans should have the same fraud prevention tools as plans in Parts A & B. In Parts A and B (and Medicaid) health plans have stronger authority to detect fraud and suspend payments. Allowing Part D plans – like payers for Parts A and B – to suspend reimbursements based on a “credible allegation” of fraud, and use the same 30-day reimbursement schedule used to pay doctors and hospitals in Medicare, will also prevent abusers from obtaining fraudulent drugs.

Recently introduced legislation by Rep. Kevin Brady (R-TX), chairman of the Ways and Means Subcommittee on Health, and separate legislation introduced by Reps. Gus Bilirakis (R-FL) and Ben Ray Luján (D-NM), each include policy solutions that could help reduce prescription drug fraud and abuse.