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Webinar Details

  • Pub Code: C4A33-11WEB
  • Speakers
    • Steve Arbaugh
    • Jane Galvin
    • Anne Hance

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Avoiding Costly Part D Sanctions: Rx Access Strategies for Plans and PBMs

August 5, 2014 Webinar - Listen On-Demand or Get a CD!

The immediate suspensions that CMS imposed on Capital BlueCross in late May — prohibiting it from marketing to or enrolling new Part D plan members — were just the latest in a series of stiff sanctions regulators have applied to health plans for providing inadequate access to prescription drugs. Agency audits are uncovering violations that pose serious threats to the health and safety of beneficiaries in areas such as rejected pharmacy claims and misclassifications of drug coverage determinations, and CMS is taking quick and firm actions to halt them. Learn the details of what CMS is looking for and steps you can take to make sure plans and PBMs don’t wind up in the crosshairs of government regulators.

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The On-Demand recording will be available immediately upon purchase* as a link within a PDF file of the accompanying written materials. CDs and printed materials are shipped via USPS.

Sponsored by Atlantic Information Services, Inc., publisher of Medicare Advantage News, Health Plan Week, Drug Benefit News and Specialty Pharmacy News

Regulators are being flooded with complaints — from beneficiaries and providers — about Part D and other health plan enrollees not getting timely access to prescription drugs, often because of faulty utilization-management, prior-authorization or step-therapy policies, and faulty processes for transition supplies of pharmaceuticals.

The result has been a host of costly sanctions for Medicare plans that, in addition to highly publicized marketing and enrollment suspensions, have involved significant civil monetary penalties and demands for immediate corrective actions. And CMS is flexing its regulatory muscles further, instituting new regulatory requirements that include a revised Notice of Denial of Medicare Prescription Drug Coverage that Part D sponsors must use. Many of the same issues apply to other plans, including Medicaid.

Hear one of the industry’s most experienced Part D consultants, a top health plan attorney and the BlueCross and BlueShield Association’s regulatory director analyze the CMS requirements that are causing plans so much trouble … and offer strategies plans and their partners can institute to prevent pharmaceutical-access problems. You’ll get answers to these and other questions:

  • What are the statutory and regulatory requirements regarding access to pharmaceuticals in Part D? How are they likely to change in the near future?
  • What is CMS finding in terms of violations of drug-access standards in its audits and via member complaints? What actions is the agency taking in response, including civil monetary penalties and intermediate sanctions?
  • What steps does CMS expect Part D plans to take to monitor and oversee their PBMs?
  • What specifically are regulators looking for in plans’ policies on the use of prior authorization, step therapy and transition supplies of medications?
  • How do CMS’s recent revisions to the Notice of Denial of Medicare Prescription Drug Coverage change the requirements that plans and their partners must comply with?
  • What do regulators expect from plans in their handling of protests and appeals of coverage determinations on pharmaceuticals?
  • How should plans and PBMs administer formularies to avoid access problems despite the necessity for frequent changes?
  • What does CMS expect in terms of outreach to prescribers and beneficiaries on pharmaceutical-access issues? What operational and other strategies should plans employ to accomplish this?


STEVE ARBAUGH is managing principal and CEO of ATTAC Consulting Group, LLC and serves as practice director of its Health Plan Management and Government Programs group, which includes Medicare Advantage and Part D. Mr. Arbaugh previously served as CEO and chief operating officer of various insurance and managed care organizations, including several stints as CEO of health plans during turnaround situations. Before joining ATTAC as a founding member, he held positions with organizations that included UnitedHealthcare, First Care and Care Choices Health Plans and was executive vice president of Gorman Health Group, LLC.

JANE GALVIN is the managing director of regulatory affairs for the BlueCross and BlueShield Association in their Washington, D.C., Office of Policy and Representation. Ms. Galvin’s responsibilities at BCBSA include working with Blue Plans on regulatory and other health care issues that impact Plan business and working directly with critical government agencies, such as the U.S. Departments of Labor, Health and Human Services, Treasury and also the Centers for Medicare and Medicaid Services on the issues and concerns of Plans as they related to federal regulatory matters. She has close working relationships with CMS on Medicare Advantage, Part D and other issues. Her professional experiences span several decades in Washington, D.C., including working for a member of Congress in the House of Representatives and serving in Washington, D.C., based trade associations. She also held management positions with Kaiser Permanente in their Mid-Atlantic Region in the D.C. area.

ANNE HANCE is a partner in the McDermott Will & Emery law firm, based in its Washington, D.C., office. She is a member of the firm’s Health Industry Advisory Practice Group and co-chair of its Insurance/Payors Affinity Group. Ms. Hance counsels clients on a broad range of issues, including the Medicare Advantage and Part D programs. In addition, she has served as vice-chair in charge of publications for the American Health Lawyers Association’s Payors, Plans and Managed Care Practice Group, and is co-editor of AHLA’s Managed Care Contracting Handbook.

Moderator: Jill Brown, executive editor at Atlantic Information Services, Inc.

Designed Especially For

  • Medicare Advantage, Part D and Medicaid health plan CEOs, CFOs, chief operating officers, pharmacy directors, pharmacy & therapeutics committee members, government affairs and compliance directors, sales and marketing executives, provider relations directors, attorneys, accountants and actuaries.
  • Pharmacy benefit manager and pharmaceutical company executives.
  • Provider group CEOs, administrators and directors of managed care contracting.
  • Executives of health care information technology firms and pharmacy chains.
  • Attorneys, consultants and actuaries.

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Avoiding Costly Part D Sanctions: Rx Access Strategies for Plans and PBMs

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