Inappropriate Medicare Part D Payments for Schedule II Drugs Billed as Refills

WHY WE DID THIS STUDY

Schedule II drugs have the highest potential for abuse of any prescription drugs legally available in the United States. They include narcotics commonly used to relieve pain and stimulants. Federal law prohibits the refilling of prescriptions for them. In addition, Schedule II drugs cannot be dispensed without a prescription that contains the name, address, and signature of the prescriber.

HOW WE DID THIS STUDY

We based this study on an analysis of prescription drug event records. Sponsors submit these records to CMS for each drug dispensed to beneficiaries enrolled in their plans. Each record contains information about the pharmacy, prescriber, and drug. We analyzed all of the records for refills of Schedule II drugs that were billed in 2009.

WHAT WE FOUND

Medicare Part D inappropriately paid $25 million for Schedule II drugs billed as refills in 2009. Sponsors should not have paid for any of these drugs because Federal law prohibits the refilling of Schedule II controlled substances. Some of these drugs may have been inaccurately billed. It is possible that some long-term-care pharmacies incorrectly billed these drugs as refills when they were partial fills. Partial fills occur when a pharmacist does not dispense all doses of the prescribed medication at one time. Several concerns exist, however, if partial fills are inaccurately billed as refills. Moreover, over 25,000 Schedule II refills had invalid prescribers. Lastly, three-quarters of Part D sponsors paid for Schedule II drugs billed as refills, indicating that many sponsors do not have adequate controls to prevent these refills.

WHAT WE RECOMMEND

We recommend that CMS: (1) issue guidance to sponsors to prevent billing of Schedule II refills and to ensure accurate billing of partial fills; (2) exclude Schedule II refills when calculating payments to sponsors; (3) monitor sponsors to ensure that they validate prescriber numbers for Schedule II drugs; and (4) follow up on sponsors, pharmacies, and prescribers with high numbers of refills. CMS concurred with our recommendation to monitor sponsors to ensure they validate prescriber numbers and partially concurred with the other three recommendations.