CMS lifts Smart D (Express Scripts) Medicare Part D Marketing and Enrollment Sanctions

On April 23, 2015, the Centers for Medicare and Medicaid Services (CMS) lifted the Intermediate Sanctions on Smart Insurance Company (Smart) Stand-Alone Medicare Part D Prescription Drug Plans (contract number S0064) that had suspended the Smart marketing and enrollment activities.

Express Scripts, Inc. (Express Scripts) acquired the Smart PDP contract on September 1, 2013, taking ownership of the contract and responsibility for remediating the problems that caused the CMS sanctions.

According to the CMS letter:

"CMS conducted validation audits in 2015 to evaluate whether the deficiencies were corrected and not likely to recur. Based on the results of the validation audits, CMS has determined that Express Scripts’ deficiencies have been sufficiently corrected. Therefore, effective April 23, 2015, the intermediate sanctions are released from contract S0064. Additionally, the limited enrollment period has ended and Express Scripts will return to normal marketing and enrollment status."

The 2013 Smart PDP sanctions were imposed based on findings from a program audit conducted in March 2013, which found compliance failures that included:

Inappropriate rejection of drug claims at the point of sale (i.e., pharmacy counter);
Failure to properly process coverage determinations (i.e., requests for drug coverage or payment and reimbursement);
Denying enrollees the chance to appeal rejected claims and failure to ensure that denied coverage determinations were reviewed by an independent third party; and
Failure to process enrollment and disenrollment requests, or failure to properly process enrollment transactions.

For more details, see the CMS "Notice of Release of Intermediate Sanctions (Suspension of Marketing and Enrollment) for Prescription Drug Plan Contract Number: S0064" here:
https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/Enforcement-Letters-Items/ESISanctionRelease042315.html