GAO-12-104T, Medicare Part D: Instances of Questionable Access to Prescription Drugs


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United States Government Accountability Office: 
GAO: 

Testimony: 

Before the Subcommittee on Federal Financial Management, Government 
Information, Federal Services, and International Security, Committee 
on Homeland Security and Governmental Affairs, U.S. Senate: 

For Release on Delivery: 
Expected at 10:30 a.m. EDT:
Tuesday, October 4, 2011: 

Medicare Part D: 

Instances of Questionable Access to Prescription Drugs: 

Statement of Gregory D. Kutz: 
Director, Forensic Audits and Special Investigations: 

GAO-12-104T: 

Chairman Carper, Ranking Member Brown, and Members of the Subcommittee: 

Thank you for the opportunity to discuss the results of our 
investigation of fraud and prescription drug abuse in Medicare Part D. 
Prescription drug abuse is a serious and growing public health 
problem. According to the Centers for Disease Control and Prevention, 
drug overdoses, including those from prescription drugs, are the 
second leading cause of deaths from unintentional injuries in the 
United States, exceeded only by motor vehicle fatalities. Unlike 
addiction to heroin and other drugs that have no accepted medical use, 
addiction to some controlled substances can be unknowingly financed by 
insurance companies and public programs, such as Medicare Part D. 

My statement today summarizes our report,[Footnote 1] describing 
indications of doctor shopping in the Medicare Part D program for 14 
categories of frequently abused prescription drugs.[Footnote 2] The 
objectives of the forensic audit and related investigation were to (1) 
determine the extent to which Medicare beneficiaries obtained 
frequently abused drugs from multiple prescribers, (2) identify 
examples of doctor shopping activity, and (3) determine the actions 
taken by the Centers for Medicaid & Medicare Services (CMS) to limit 
access to drugs for known abusers. To meet the objectives, we analyzed 
Medicare Part D claims for calendar year 2008 to identify potential 
doctor shoppers. To identify examples, we chose a nonrepresentative 
selection of 10 beneficiaries based on a number of factors, including 
the number of prescribers. 

We conducted this forensic audit from May 2010 to October 2011 in 
accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. We conducted 
our related investigative work in accordance with standards prescribed 
by the Council of the Inspectors General on Integrity and Efficiency. 

Some Medicare Beneficiaries Received Prescriptions from Five or More 
Medical Practitioners to Obtain the Same Class of Frequently Abused 
Drugs: 

Our analysis found that about 170,000 Medicare beneficiaries received 
prescriptions from five or more medical practitioners for the 12 
classes of frequently abused controlled substances and 2 classes of 
frequently abused noncontrolled substances in calendar year 2008. 
[Footnote 3] This represented about 1.8 percent of the Medicare Part D 
beneficiaries who received prescriptions for these 14 classes of drugs 
during the same calendar year. These individuals incurred 
approximately $148 million in prescription drug costs[Footnote 4] for 
these drugs,[Footnote 5] much of which is paid by the Medicare 
program. We also found the following: 

* Most of these 170,000 Medicare beneficiaries who were prescribed 
prescriptions from five or more practitioners were eligible for 
Medicare Part D benefits based on a disability. Specifically, 
approximately 120,000 Medicare beneficiaries (about 71 percent) were 
eligible for Medicare Part D benefits based on a disability. 

* Of these 170,000 beneficiaries, approximately 122,000 beneficiaries 
(72 percent) received a Medicare Low-Income Cost-Sharing (LICS) 
subsidy.[Footnote 6] 

* Of the 14 classes of frequently abused drugs analyzed, hydrocodone 
and oxycodone were the most prevalent. These drugs represented over 80 
percent of the instances of potential doctor shopping we identified. 

In some cases, beneficiaries may have a justifiable reason for 
receiving prescriptions from multiple medical practitioners, such as 
visiting specialists or several prescribers in the same medical group. 
However, our analysis of Medicare Part D claims found that about 600 
Medicare beneficiaries received prescriptions from 21 to 87 medical 
practitioners in the same year. In these situations, there is 
heightened concern that these Medicare beneficiaries may be seeking 
several medical practitioners to support and disguise an addiction. 
[Footnote 7] 

Our analysis of Medicare Part D claims did not focus on all 
prescription drugs, but instead targeted 12 classes of frequently 
abused controlled substances and 2 classes of frequently abused 
noncontrolled substances, as shown in table 1. Our analysis does have 
certain limitations based on the data. Specifically, for at least 5.8 
percent of the Part D claims, the data submitted to CMS contained 
blank or invalid prescriber identification values. Because these 
claims were not included in our analysis, we potentially understated 
the total number of unique prescribers for each beneficiary who 
received a prescription for all the claims paid. 

Table 1: Fourteen Frequently Abused Prescription Drugs Classes: 

Prescription drug classes: Amphetamine derivatives; 
Other names: Adderall; 
DEA schedule[A]: II; 
Description: Non-narcotic stimulant. 

Prescription drug classes: Benzodiazepines[B] (e.g., Diazepam, 
Alprazolam, Lorazepam, Clonazepam, Temazepam, and Triazolam); 
Other names: Valium, Xanax, Klonopin, Ativan, Restoril, and Halcion; 
DEA schedule[A]: IV; 
Description: Non-narcotic depressant. 

Prescription drug classes: Carisoprodol; 
Other names: Soma; 
DEA schedule[A]: Not scheduled; 
Description: Muscle relaxant. 

Prescription drug classes: Codeine with Acetaminophen; 
Other names: Tylenol with Codeine; 
DEA schedule[A]: III; 
Description: Narcotic painkiller. 

Prescription drug classes: Fentanyl; 
Other names: Duragesic and Actiq; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Hydrocodone combinations; 
Other names: Lorcet, Lortab, Norco, and Vicodin; 
DEA schedule[A]: III; 
Description: Narcotic painkiller. 

Prescription drug classes: Hydromorphone; 
Other names: Dilaudid; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Meperidine; 
Other names: Demerol; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Methadone[C]; 
Other names: Methadose and Dolophine; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Methylphenidate; 
Other names: Ritalin, Concerta, and Methylin; 
DEA schedule[A]: II; 
Description: Non-narcotic stimulant. 

Prescription drug classes: Morphine; 
Other names: MS Contin, Roxanol, Avinza, and Kadian; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Non-Benzodiazepine sleep aids (e.g., 
Zolpidem, Zopiclone, and Zaleplon); 
Other names: Ambien, Sonata, and Lunesta; 
DEA schedule[A]: IV; 
Description: Non-narcotic sedative. 

Prescription drug classes: Oxycodone; 
Other names: OxyContin, Roxicodone, Percocet, Endocet, and Roxicet; 
DEA schedule[A]: II; 
Description: Narcotic painkiller. 

Prescription drug classes: Tramadol; 
Other names: Ultram and Ultracet; 
DEA schedule[A]: Not scheduled; 
Description: Non-narcotic painkiller. 

Sources: National Institutes of Health and Drug Enforcement 
Administration. 

[A] The Drug Enforcement Administration (DEA) classifies controlled 
substances in schedules I through V. Schedule I drugs--including 
heroin, marijuana, and hallucinogens such as LSD--have a high 
potential for abuse and no federally accepted medical use. Schedule II 
drugs have a high potential for abuse and may lead to severe physical 
or psychological dependence but have a currently accepted medical use. 
Drugs on schedules III through V have medical uses and successively 
lower potentials for abuse and dependence. 

[B] Part D plans are not required to cover benzodiazepines. However, 
some plans choose to cover these drugs as an added benefit. 

[C] Methadone is also used for the treatment of narcotic withdrawal 
and dependence. 

[End of table] 

Table 2 shows the breakout by drug class for the approximately 170,000 
Medicare Part D beneficiaries who were prescribed the same class of 
drug by five or more medical practitioners. Because Medicare Part D 
beneficiaries may be receiving multiple classes of prescription drugs 
from five or more medical practitioners, certain beneficiaries may be 
counted in more than one prescription drug class. As shown in table 2, 
hydrocodone and oxycodone were the two prescription drug classes that 
were most prescribed by multiple medical practitioners. According to 
the Department of Justice (DOJ), doctor shopping is the primary method 
to obtain highly addictive prescription opioids (e.g., hydrocodone and 
oxycodone) for illegitimate use.[Footnote 8] 

Table 2: Number of Medicare Part D Beneficiaries Who Received 1 of 14 
Prescription Drug Classes from Five or More Prescribers in 2008: 

Amphetamine derivatives (e.g., Adderall); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 881; 
11-15: 9; 
16-20: 3; 
21-50: 2; 
51+: 0; 
Total: 895; 
Total prescription cost: $1,040,395. 

Benzodiazepine (e.g., Valium and Xanax); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 2,437; 
11-15: 17; 
16-20: 4; 
21-50: 2; 
51+: 0; 
Total: 2,460; 
Total prescription cost: $372,822. 

Carisoprodol (e.g., Soma); 
DEA controlled: N; 
Number of prescribers: 
5-10: 3,026; 
11-15: 51; 
16-20: 4; 
21-50: 2; 
51+: 0; 
Total: 3,083; 
Total prescription cost: $592,751. 

Codeine with Acetaminophen (e.g., Tylenol with Codeine); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 1,500; 
11-15: 21; 
16-20: 4; 
21-50: 0; 
51+: 0; 
Total: 1,525; 
Total prescription cost: $244,930. 

Fentanyl (e.g., Duragesic); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 5,043; 
11-15: 24; 
16-20: 8; 
21-50: 2; 
51+: 0; 
Total: 5,077; 
Total prescription cost: $19,124,853. 

Hydrocodone (e.g., Vicodin and Lortab); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 92,801; 
11-15: 3,553; 
16-20: 700; 
21-50: 335; 
51+: 5; 
Total: 97,394; 
Total prescription cost: $18,949,677. 

Hydromorphone (e.g., Dilaudid); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 2,453; 
11-15: 77; 
16-20: 13; 
21-50: 8; 
51+: 0; 
Total: 2,551; 
Total prescription cost: $1,236,678. 

Meperidine (e.g., Demerol); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 149; 
11-15: 8; 
16-20: 0; 
21-50: 0; 
51+: 0; 
Total: 157; 
Total prescription cost: $90,236. 

Methadone (e.g., Dolophine and Methadose); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 3,414; 
11-15: 9; 
16-20: 0; 
21-50: 0; 
51+: 0; 
Total: 3,423; 
Total prescription cost: $859,208. 

Methylphenidate (e.g., Ritalin and Concerta); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 740; 
11-15: 2; 
16-20: 1; 
21-50: 0; 
51+: 0; 
Total: 743; 
Total prescription cost: $488,759. 

Morphine (e.g., MS Contin and AVINZA); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 6,354; 
11-15: 33; 
16-20: 4; 
21-50: 0; 
51+: 0; 
Total: 6,391; 
Total prescription cost: $9,311,773. 

Non-Benzodiazepine sleep aids (e.g., Ambien and Lunesta); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 4,496; 
11-15: 15; 
16-20: 0; 
21-50: 0; 
51+: 0; 
Total: 4,511; 
Total prescription cost: $2,917,465. 

Oxycodone (e.g., Oxycontin and Percodan); 
DEA controlled: Y; 
Number of prescribers: 
5-10: 54,183; 
11-15: 1,974; 
16-20: 440; 
21-50: 235; 
51+: 5; 
Total: 56,837; 
Total prescription cost: $91,681,281. 

Tramadol (e.g., Ultram and Ultracet); 
DEA controlled: N; 
Number of prescribers: 
5-10: 4,346; 
11-15: 134; 
16-20: 33; 
21-50: 14; 
51+: 0; 
Total: 4,527; 
Total prescription cost: $1,037,423. 

Total; 
Number of prescribers: 
5-10: 181,823; 
11-15: 5,927; 
16-20: 1,214; 
21-50: 600; 
51+: 10; 
Total: 189,574; 
Total prescription cost: $147,948,251. 

Sources: GAO and DEA. 

Notes: The totals do not necessarily represent unique beneficiaries. A 
single beneficiary could have been prescribed more than one class of 
drug by more than one prescriber. The number of unique beneficiaries 
represented in this table is 170,029. The maximum number of 
prescribers from which a beneficiary received 1 of the 14 classes of 
prescription drugs was 87. The total beneficiary counts for oxycodone 
and hydrocodone represent 2.8 percent and 1.8 percent of all 
beneficiaries receiving that class of drug, respectively. 

[End of table] 

Examples of Doctor Shopping in Medicare Part D: 

We obtained additional information on 10 of the Medicare Part D 
beneficiaries that showed indications of doctor shopping. In each of 
the 10 cases, we found evidence that the beneficiary was acquiring 
highly abused drugs through doctor shopping. We also found that in 
each example physicians were not aware that their patients were 
receiving drugs prescribed by other prescribers. DEA's definition of 
doctor shopping specifies an individual receiving more of a drug than 
intended by any single physician. In several examples physicians 
stated that they would not have prescribed the drugs if they were 
aware that the patient was receiving the same class of drugs from 
other sources. Table 3 highlights 3 of the 10 examples of doctor 
shopping for prescription drugs, including controlled substances, in 
the Medicare Part D program. We referred these beneficiaries to the 
Medicare Part D fraud contractor, as appropriate, for further 
investigation.[Footnote 9] 

Table 3: Examples of Doctor Shopping of Prescription Drugs in Medicare 
Part D: 

Example: 1; 
State: CA; 
Class of prescription drug(s): Fentanyl; 
Case details: 
* The beneficiary received prescriptions for a total of 1,397 fentanyl 
patches and pills (a 1,758-day supply) from 21 different prescribers 
in 2008; 
* One physician who treated the beneficiary prescribed fentanyl for 
lower back pain. The beneficiary did not inform the physician that he 
was seeing other doctors. The physician stated that he would not have 
prescribed any controlled substances had he known they were being 
prescribed by other doctors; 
* Another physician who treated the beneficiary from March 2008 
through August 2008 stated that the beneficiary did not disclose that 
he was seeing other doctors and that she would not have prescribed any 
controlled substances had she known they were being prescribed by 
other doctors. In August 2008, the physician received an alert 
letter[A] from the state prescription drug monitoring program (PDMP) 
informing her that within a 4-month period the beneficiary had 
received 33 prescriptions for controlled substances from 10 different 
prescribers. After the PDMP alerted the physician of these multiple 
prescribers, the physician informed the beneficiary that she would no 
longer treat him as a patient. 

Example: 2; 
State: GA; 
Class of prescription drug(s): Oxycodone; 
Case details: 
* The beneficiary received prescriptions for a total of 3,655 
oxycodone pills (a 1,679-day supply) from 58 different prescribers in 
2008. The beneficiary received a prescription for at least 1 of the 14 
selected drugs from at least 66 different prescribers, and she filled 
her prescriptions at 45 different pharmacies in 2008; 
* A pharmacy discovered that the beneficiary was forging a 
prescription from a physician. The pharmacy has noted in its system 
that its store and other pharmacies in the chain should refuse to fill 
controlled substances prescriptions for this beneficiary; 
* Another pharmacy refused to fill a prescription for the beneficiary, 
after believing that the beneficiary tried to fill a forged 
prescription at the store. The beneficiary has not returned to the 
store since that refusal; 
* A physician who frequently treated the beneficiary was repeatedly 
asked for early refills of Oxycontin prescriptions. After the 
physician would no longer prescribe Oxycontin, the beneficiary's 
medical visits to him ceased. The beneficiary did not inform the 
physician about seeing other physicians. The physician would not have 
prescribed any controlled substances had he known they were being 
prescribed by other physicians; 
* Another physician stated that he was suspicious of the beneficiary's 
need for the drugs because (1) the beneficiary stated a desire for 
Oxycontin because of an allergy to other drugs and (2) the beneficiary 
refused to see a specialist despite his repeated directions. The 
beneficiary quit seeing the physician after the physician refused to 
prescribe any more narcotics. The physician was not aware of any 
attempted forgeries, but stated that he would not be surprised because 
it is easy to forge prescriptions in Georgia. The physician stated 
that Georgia has no requirements that prescriptions be written on any 
type of special security paper and that an individual can simply print 
or copy a prescription at home using a personal computer and regular 
computer paper. 

Example: 3; 
State: TX; 
Class of prescription drug(s): Hydrocodone; 
Case details: 
* The beneficiary received prescriptions for a total of 4,574 
hydrocodone pills (a 994-day supply) from 25 different prescribers in 
2008; 
* A previous physician stated that the beneficiary was obligated to 
inform him about receiving other prescriptions for controlled 
substances. The physician stated that he did not know that other 
physicians were prescribing narcotics to the beneficiary. The 
physician stated that it was medically unnecessary, and possibly 
dangerous, to consume the amount of narcotics obtained by the 
beneficiary. Had he been informed that the beneficiary was receiving 
narcotics from other doctors, the physician would have ceased 
prescribing the drugs. 

Source: GAO. 

[A] Prescribers can receive alert letters from state PDMPs and from 
Part D plan sponsors. 

[End of table] 

Figure 1 illustrates the doctor shopping activity from example 2. This 
beneficiary received a 150-day supply of oxycodone in just 27 days by 
obtaining seven prescriptions from four different prescribers. 

Figure 1: Medicare Part D Beneficiary Visits Four Doctors to Obtain 
Oxycodone: 

[Refer to PDF for image: illustration] 

Dr.A: 15-day supply. 

1 day later: 
Dr. B: 20-day supply. 

4 days later: 
Dr.C: 30-day supply. 

7 days later: 
Dr.D: 2-day supply. 

4 days later: 
Dr.A: 45-day supply. 

10 days later: 
Dr.D: 8-day supply. 

Same day: 
Dr.C: 30-day supply. 

Source: GAO analysis of Medicare Part D claims data for calendar year 
2008. 

[End of figure] 

Systems Are in Place to Identify Inappropriate Drug Use, but Measures 
to Stop the Activity Are Limited: 

CMS requires Part D plans to perform retrospective drug utilization 
review (DUR) analysis to identify prior inappropriate or unnecessary 
medication use and provide education, such as alert letters, to the 
prescribers involved. By analyzing historical prescription claims 
data, the drug plans can identify individuals who are likely obtaining 
excessive amounts of highly abused drugs or potentially seeking such 
drugs from multiple medical practitioners. However, according to CMS 
Part D program officials, federal law does not authorize Part D plans 
to restrict the access of these individuals, leaving little recourse 
for preventing known doctor shoppers from obtaining hydrocodone, 
oxycodone, and other highly abused drugs. 

Officials from the Part D plan sponsors we interviewed stated that 
controls in place in the Medicaid program and in some private sector 
plans could be used to better restrict the dispensing of abused drugs 
to individuals identified as doctor shoppers through detecting a 
pattern of abuse during retrospective analysis. Such programs employ a 
restricted recipient program, or "lock-in" program, where prescription 
drug plans restrict beneficiaries who have been identified as drug 
abusers to one prescriber, one pharmacy, or both for receiving 
prescriptions. However, as mentioned, CMS Part D program officials' 
interpretation of federal law prevents such a program from being 
implemented. 

Further, effective retrospective DURs require prescription drug plans 
to be able to share information about individuals identified as doctor 
shoppers with other Part D plans, as appropriate. Even if a restricted 
recipient program were implemented, according to CMS officials, 
Medicare Part D plan sponsors are not allowed to share beneficiary 
information with other plans. As a result, a Medicare Part D plan 
sponsor cannot forewarn another Medicare Part D plan sponsor when an 
identified doctor shopper has left its plan and enrolled in another. 
Because Medicare Part D beneficiaries can change prescription drug 
plans on at least a yearly basis, beneficiaries may be able to switch 
plans and continue their doctor shopping activity. Thus, to prevent 
known doctor shoppers from circumventing a restricted recipient 
program, a mechanism would also need to be established that allows CMS 
or its fraud contractor to inform the new plan of the doctor shopping 
activities of the beneficiary. Without such notification, 
beneficiaries will be able to bypass a restricted recipient program 
merely by switching prescription drug plans. 

Recommendations for Executive Action: 

In our report, we recommended that the Administrator of CMS should 
review our findings, evaluate the existing DUR program, and consider 
additional steps, such as a restricted recipient program for Medicare 
Part D that would limit identified doctor shoppers to one prescriber, 
one pharmacy, or both for receiving prescriptions. We stated that CMS 
should consider the experiences from Medicaid and private sector use 
of such restricted recipient programs, including weighing the 
potential costs and benefits of instituting the control. We also 
stated that along with a restricted recipient program, CMS should 
consider facilitating the sharing of information on identified doctor 
shoppers among the Part D drug plan sponsors so that those 
beneficiaries cannot circumvent the program by switching prescription 
drug plans. Finally, we stated that in considering such controls, CMS 
should seek congressional authority, as appropriate. 

CMS Comments and Our Evaluation: 

In response to a draft of our report, CMS agreed with our overall 
recommendation to improve efforts to curb overutilization in Part D, 
but disagreed that a restricted recipient program is necessarily the 
appropriate control for the Part D program. CMS also stated that it is 
undertaking an additional evaluation of data on potential 
overutilization to identify potential solutions and that it will issue 
program guidance to Part D sponsors on any best practices and develop 
an internal monitoring strategy. We support CMS looking into both 
enhanced point-of-sale and retrospective controls and related actions 
to address overutilization and questionable access to specific drugs. 
We believe that a restricted recipient program should be part of CMS's 
assessment. It can be used for known abusers identified by 
retrospective DURs while not jeopardizing legitimate patient access to 
care. 

CMS also stated that GAO provided no evidence that a restricted 
recipient program would be more effective than existing DUR 
requirements. Our intent was not to prescribe a restricted recipient 
program as the only solution, but instead for CMS to consider 
utilizing it along with other existing controls. As previously 
discussed, Part D plan sponsor officials we interviewed stated that a 
restricted recipient program could better restrict the dispensing of 
abused drugs. CMS also provided a written statement to this 
Subcommittee in 2009 asserting that a restricted recipient program, or 
"lock-in" program, is a proven mechanism in the Medicaid program to 
minimize misuse.[Footnote 10] Thus, we continue to believe a 
restricted recipient program warrants further consideration. 

Chairman Carper, Ranking Member Brown, and Members of the 
Subcommittee, this completes my prepared statement. I would be pleased 
to respond to any questions that you may have at this time. 

GAO Contact: 

For further information regarding this testimony, please contact me at 
(202) 512-6722 or kutzg@gao.gov. Contact points for our Offices of 
Congressional Relations and Public Affairs may be found on the last 
page of this statement. 

[End of section] 

Footnotes: 

[1] GAO, Medicare Part D: Instances of Questionable Access to 
Prescription Drugs, [hyperlink, 
http://www.gao.gov/products/GAO-11-699] (Washington, D.C.: Sept. 6, 
2011). 

[2] According to the Drug Enforcement Administration, doctor shopping 
generally refers to visits by an individual to several doctors, each 
of whom writes a prescription for a controlled substance. The 
individual will visit several pharmacies, receiving more of the drug 
than intended by any single physician, typically for the purpose of 
abuse. 

[3] We selected the 14 classes of drugs and the five or more 
prescribers threshold based on our review of drug diversion literature 
and prior GAO work and discussions with a criminal investigator whose 
recognized expertise is in drug diversion and with an official 
representing state prescription drug monitoring programs. 

[4] Medicare Part D is financed from general revenues, beneficiary 
premiums, and state contributions for Medicare beneficiaries who are 
also eligible for Medicaid. A beneficiary premium is set to cover 
approximately 25 percent of the cost of standard drug coverage. 

[5] The $148 million in prescription costs represents about 5 percent 
of total Medicare Part D prescription costs for these14 classes of 
highly abused drugs. The prescription drug costs included in this 
study do not include related costs associated with obtaining 
prescriptions, such as the corresponding visits to the doctor's office 
and emergency room. These costs are billed separately from the 
prescription drug claims. 

[6] When Medicare Part D was established, it replaced Medicaid as the 
primary source of drug coverage for beneficiaries with coverage under 
both programs--referred to as dual-eligible beneficiaries. Part D 
provides substantial premium and cost-sharing assistance through the 
LICS for dual-eligible beneficiaries and other low-income 
beneficiaries. The amount of the subsidy for premiums, deductibles, co-
payments, and catastrophic coverage varies depending on income and 
resources. 

[7] Our threshold of visiting five or more practitioners excludes 
those who successfully doctor shop by visiting fewer than five 
practitioners on a regular basis. For example, a Medicare beneficiary 
can regularly receive overlapping prescriptions of abused drugs by 
visiting as few as two practitioners. 

[8] DOJ, National Prescription Drug Threat Assessment 2010 (NPDTA 10) 
(Johnstown, Pa.: February 2010). 

[9] CMS guidance directs Part D plans to refer cases of potential 
fraud directly to the Medicare Part D fraud contractor. 

[10] A Prescription for Waste: Controlled Substance Abuse in Medicaid, 
Before the Subcommittee on Federal Financial Management, Government 
Information, Federal Services, and International Security, 111th Cong. 
(2009) (posthearing Questions for the Record Submitted to Penny 
Thompson, Deputy Director, Center for Medicaid and State Operations, 
Centers for Medicare & Medicaid Services, from Senator Tom Carper). 

[End of section] 

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Washington, D.C. 20548: 

Public Affairs: 

Chuck Young, Managing Director, youngc1@gao.gov: 
(202) 512-4800: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7149: 
Washington, D.C. 20548: