Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
M P  
EDICARE  AID FOR 
 
 
HIV D  
  RUGS FOR 
 
 
D B
ECEASED  ENEFICIARIES 
 
 
 
 
Suzanne Murrin  
Deputy Inspector General for 
Evaluation and Inspections 
 
October 2014 
OEI-02-11-00172   
   
Medicare Paid for HIV Drugs for Deceased Beneficiaries 
OEI-02-11-00172 
 
WHY WE DID THIS STUDY 
Under the Medicare Part D program, the Centers for Medicare & Medicaid Services 
(CMS) contracts with private insurance companies, known as sponsors, to provide 
prescription drug coverage to beneficiaries who choose to enroll.  The Office of Inspector 
General (OIG) has had ongoing concerns about Medicare paying for drugs and services 
after a beneficiary has died.   
 
Drugs that treat the human immunodeficiency virus (HIV) can be a target for fraud, 
waste, and abuse, primarily because they can be very expensive.  Although this report 
focuses on HIV drugs, the issues raised are relevant to all Part D drugs. 
 
HOW WE DID THIS STUDY  
We based this study on an analysis of Prescription Drug Event (PDE) records for HIV 
drugs in 2012.  Part D sponsors submit these records to CMS for each drug dispensed to 
beneficiaries enrolled in their plans.  Each record contains information about the drug, 
beneficiary, pharmacy, and prescriber.  We used the Beneficiary Enrollment Database, 
the Social Security Administrations Death Master File, and Accurints Death Records to 
identify beneficiaries dates of death. 
 
WHAT WE FOUND 
Medicare paid for HIV drugs for over 150 deceased beneficiaries.  CMSs current  
practices allowed most of these payments to occur.  Specifically, CMS has edits 
(i.e., systems processes) in place that reject PDE records for drugs with dates of service 
more than 32 days after death. CMSs practices allow payment for drugs that do not meet 
Medicare Part D coverage requirements.  Most of these drugs were dispensed by retail 
pharmacies.   
 
This review looked only at HIV drugs, which account for one-quarter of one percent of 
all Part D drugs in 2012.  However, our findings have implications for all drugs because 
Medicare processes PDE records for all drugs the same way.  Considering the enormous 
number of Part D drugs, a change in practice would affect all Part D drugs and could 
result in significant cost savings for the program  and for taxpayers. 
 
WHAT WE RECOMMEND 
We recommend that CMS change its practice of paying for drugs that have a date of 
service within 32 days after the beneficiarys death.  CMS should eliminate orif 
necessary  for administrative processing issuesshorten the window in which it accepts 
PDE records for drugs dispensed after a beneficiarys death.  Such a change would 
prevent inappropriate payments for drugs for deceased beneficiaries and lead to cost  
savings for the program and for taxpayers.  CMS concurred with our recommendation. 
 
   
TABLE OF CONTENTS 
 
Objective......................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Findings........................................................................................................7 

Medicare paid for HIV drugs for over 150 deceased beneficiaries 

as a result of CMSs current practices  .............................................7 

Most of the drugs were dispensed by retail pharmacies ..................8 

Conclusion and Recommendation .............................................................10 

Agency Comments and Office of Inspector General Response .....11 
 
Appendix 

A: HIV Drugs ......................................................................................12 

B: Agency Comments  .........................................................................14 

Acknowledgments......................................................................................15
   
   
OBJECTIVE 
To determine the extent to which Medicare Part D paid for human 
immunodeficiency virus (HIV) drugs for deceased beneficiaries in 2012.  
BACKGROUND 
Medicare Part D provides an optional prescription drug benefit to 
Medicare beneficiaries. The Centers for Medicare & Medicaid Services 
(CMS) contracts with private insurance companies, known as Part D 
sponsors, to provide drug coverage to beneficiaries who choose to enroll 
in the program.1  In 2012, 37 million beneficiaries were enrolled in  
Part D.2  
The Office of Inspector General (OIG) has had ongoing concerns about 
Medicare payments for drugs and services after a beneficiary has died.  
OIG has found that although CMS has some safeguards to prevent these 
improper payments, it continues to make some payments on behalf of 
deceased beneficiaries.3   This raises questions about how effective the 
efforts of CMS and its contractors are in preventing improper payments 
and what opportunities exist for cost savings. 
This report addresses payments on behalf of deceased beneficiaries for 
Part D drugs, specifically HIV drugs.  HIV drugs are antiretroviral drugs 
that are the primary treatment of people living with HIV.  These drugs can 
be a target for fraud, waste, and abuse, primarily because they can be very 
expensive. For example, one common HIV drug costs about $1,700 for a 
months supply.  Although the report focuses on HIV drugs, the issues 
raised are relevant to all Part D drugs because controls to prevent 
payments after death are not specific to HIV drugs.   
Medicare Part D 
Medicare Part D covers drugs prescribed for medically accepted 
indications.4  Medicare beneficiaries have the option of enrolling in 
stand-alone prescription drug plans, or they may receive prescription drug 
coverage as a part of managed care plans.  The managed care plans 
____________________________________________________________ 
1  42 U.S.C.  1395w-101(a)(1)  and 1395w-112(b)(1). 
2 The Boards of Trustees, Federal Hospital  Insurance and Federal Supplementary 
Medical  Insurance Trust Funds, 2013 Annual Report of the Boards of Trustees of the 
Federal Hospital Insurance and Federal  Supplementary Medicare Insurance Trust  
Funds, pp. 151  and 157.  Accessed at  http://downloads.cms.gov/files/TR2013.pdf on  
November 26, 2013.   
3 For example, OIG, Medicare Payments Made  on Behalf of Deceased Beneficiaries in  
2011 (OEI-04-12-00130), October 2013. 
4  42 U.S.C. 1395w-102(e)(1). 
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  1 
   
   
(known as Medicare Advantage plans or Medicare Part C) also include 
medical benefits. 
Most beneficiaries are responsible for certain costs under Part D, which 
may include a monthly premium, an annual deductible, and coinsurance.5   
However, certain low-income beneficiaries are eligible to receive 
assistance to pay some or all of these Part D costs.6   These beneficiaries 
pay minimal or no co-pays for drugs. 
CMS requires that Part D sponsors develop a network of pharmacies to 
dispense drugs to beneficiaries enrolled in their plans.7   CMS requires 
these pharmacy networks to be geographically diverse and to include 
different types of pharmacies, such as retail pharmacies and 
long-term-care pharmacies.   
Pharmacies submit claims to sponsors (or to sponsors Pharmacy Benefit 
Managers) for drugs they dispense for beneficiaries.  If the medication is 
never picked up, then the pharmacy must reverse the claim and return the 
drugs to stock.8  
Sponsors then submit prescription drug event (PDE) records to CMS for 
all covered drugs that are dispensed to beneficiaries throughout the year.9   
These records include cost data as well as information about each drug, 
including the date of service, the pharmacy, and the beneficiary.  
Payments to Sponsors 
CMS makes monthly prospective payments to sponsors for each 
beneficiary enrolled in their plans.  These payments are based on the bids 
that sponsors submit before the beginning of the plan year.  Each bid 
estimates the sponsors anticipated drug costs as well as its administrative 
costs. 10  CMS uses the approved bids to determine the premium amounts 
that beneficiaries pay and the monthly payments that it makes to each  
   
____________________________________________________________ 
5  42  CFR  423.293 and 423.104(d), (e),  and (f).   

6  42  CFR  423.315(d).   

7 42 CFR   423.120.  

8 CMS, Announcement  of Calendar Year (CY) 2014 Medicare Advantage Capitation 

Rates and  Medicare Advantage and Part D Payment Policies and Final Call Letter,  

April 1, 2013, p. 144.  Accessed at http://www.cms.gov/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovContra/Downloads/RateNotice.pdf  on July 7, 2014. 
 
9 CMS, 2011 Regional  Prescription Drug Event Technical  Assistance Participant  Guide, 
p. 1-15. Accessed at http://www.csscoperations.com/internet/Cssc.nsf/files/ 
PDEParticipantGuide%20cameraready%20081811.pdf/$FIle/PDEParticipantGuide  
%20cameraready%20081811.pdf  on July 8,  2014. 
10 42 CFR   423.265(c)(1).  
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  2 
   
   
sponsor.11  These monthly payments are for three subsidiesthe direct 
subsidy, the low-income cost-sharing subsidy, and the reinsurance 
subsidy.12  
 	  The direct subsidy, together with the beneficiary premium, is 
designed to cover the sponsors cost of providing the benefit to 
each beneficiary.    
 	  The reinsurance subsidy covers the Federal Governments share 
of drugs costs for beneficiaries who reach a certain cost threshold 
(known as catastrophic coverage), and 
	   The low-income cost-sharing subsidy covers the Federal 
Governments portion of the cost-sharing payment for certain 
low-income beneficiaries.   
After the close of the plan year, CMS reconciles these monthly 
prospective payments with the actual costs incurred by the sponsors to 
determine at the end of the year whether CMS owes money to sponsors or 
sponsors owe money to CMS. 13  CMS determines each sponsors actual 
costs based primarily on the PDE records that the sponsor submits.14 If 
sponsors submit PDE records for drugs that should not have been covered 
by Part D, payments to sponsors may be too high.  This is particularly an 
issue when the PDE records submitted are for beneficiaries who receive 
the low-income cost-sharing subsidy or who have reached the catastrophic 
coverage threshold, because the Federal Government is responsible for a 
larger share of their drug costs.15    
Under current practice, CMS has edits (i.e., systems processes) in place 
that will not accept any PDE records for drugs with dates of service more 
than 32 days after the beneficiarys date of death. 16  However, according 
to CMS it is possible thatbecause of delays in receiving death 
informationit will accept a PDE with a date of service that is after the 
32-day window. For this reason, beginning with contract year 2013, CMS 
began conducting additional analysis to identify and exclude these PDE 
____________________________________________________________ 
11  42  CFR  423.286 and 423.315(b).   
12 42 CFR   423.315.   Also see, CMS, 2011 Regional  Prescription Drug Event Technical
  
Assistance Participant  Guide, pp. 1-161-18.    

13 42 CFR   423.343.  

14 CMS, 2011 Regional  Prescription Drug Event Technical  Assistance Participant  Guide, 

p. 1-15.  Sponsors are also required to report  direct and indirect remuneration, such as 
drug manufacturer  rebates. 
   
15 Part  D sponsors are also subject to risk sharing.  Risk-sharing payments may also be 

inaccurate if PDE records for noncovered  drugs are included  in reconciliation.  For more 

information about  risk sharing, see 42 CFR   423.336. 
 
16 See CMS, 2011 Regional Prescription Drug Event Technical Assistance Participant 
Guide, p. 8-13.   
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  3 
   
   
records from the reconciliation process.17  CMS has informational edits 
that alert Part D sponsors if the date of service on the PDE record is 32 or 
fewer days after the beneficiarys date of death. 
This study focuses on PDE records submitted by sponsors for drugs 
dispensed after the beneficiarys date of death because these PDE records 
affect payments to sponsors and the overall cost of the Part D program.  
See Methodology section for more detailed information. 
Related Work 
A recent OIG report found that nearly 1,600 Part D beneficiaries had 
questionable utilization patterns for HIV drugs in 2012.18 In total, 
Medicare paid $32 million for HIV drugs for these beneficiaries.  These 
beneficiaries had no indication of HIV in their Medicare histories, 
received an excessive dose or supply of HIV drugs, received HIV drugs 
from a high number of pharmacies or prescribers, or received 
contraindicated drugs. These questionable patterns indicate that 
beneficiaries may be receiving inappropriate or unnecessary drugs.  It may 
also indicate that a pharmacy is billing for drugs that a beneficiary never 
received, or that a beneficiarys identification number has been stolen. 
Another OIG report looked at the extent to which CMS made monthly 
prospective payments in 2011 to Part C and D sponsors for deceased 
beneficiaries.19  According to CMS policy, Medicare pays the sponsor the 
full payment for the month in which a beneficiary dies.  OIG found that in 
2011, CMS made monthly payments to Part C and D sponsors totaling 
$21 million for deceased beneficiaries in the months after death.   
Lastly, another OIG report found that in 2006 and 2007 CMS paid  
$3.6 million in monthly prospective payments to certain Part D sponsors 
for deceased beneficiaries.20 It found that although CMS had correctly 
stopped payments for the vast majority of deceased beneficiaries in 2006 
and 2007, its systems did not always identify and prevent improper 
payments.  In addition, CMS did not always recover on a timely basis the 
payments it had made on behalf of deceased beneficiaries.   
____________________________________________________________ 
17 CMS, Reconciliation PDE Exclusion Process, January 6, 2014.  
18 OIG,  Part D Beneficiaries with  Questionable Utilization Patterns for HIV Drugs  
 
(OEI-02-11-00170), August 2014. 

19 OIG, Medicare Payments Made on  Behalf of Deceased Beneficiaries in 2011  
 
(OEI-04-12-00130), October 2013. 

20 OIG,  Review of Medicare Payments to Prescription Drug Plans on Behalf of Deceased 
 
Enrollees (A-05-09-00027), May 2011. 

Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  4 
   
   
METHODOLOGY 
This current study takes a different approach than the two previous studies 
that have identified Part D payments made on behalf of deceased 
beneficiaries. Whereas the other studies focused on monthly prospective 
payments, this study focuses on PDE records with dates of service after 
the beneficiarys date of death.  Both the monthly payments and the 
prescription drug costs are factored into the amount that CMS ultimately 
pays for Part D. 
Analysis of HIV Drugs 
This study is based on an analysis of all PDE records for HIV drugs in 
2012. Each record contains information about the drug and beneficiary, as 
well as the identification number for the pharmacy.   
We first identified all PDE records for HIV drugs with dates of service 
from January 1 to December 31, 2012.  To do this, we matched the Food 
and Drug Administrations (FDA) list of HIV drugs to First Databank and 
Red Book to identify the National Drug Codes (NDC) for HIV drugs.21 In 
total, we identified 654 NDCs. Using these NDCs, we identified 
3,177,937 PDE records for HIV drugs that were dispensed to 
146,121 beneficiaries in 2012. These PDE records accounted for 
0.26 percent of the 1.24 billion records for all Part D drugs dispensed that 
year.  See Appendix A for a list of HIV drugs and their generic names. 
Next, we took several steps to identify beneficiaries for whom HIV drugs 
were dispensed after their date of death.  Using the Health Insurance 
Claims Number (HICN), we matched the PDE records to the Beneficiary 
Enrollment Database (EDB) to determine the beneficiarys date of the 
death. Next, we compared the beneficiarys date of death with the date of 
service on the PDE record. 
For records where the date of service was after the date of death, we took 
additional steps to ensure the date of death listed in the EDB was accurate.  
Specifically, we consulted two additional sourcesthe Social Security 
Administrations Death Master File and Accurints Death Recordsto 
____________________________________________________________ 
21 FDA,  Antiretroviral Drugs Used in the Treatment of HIV Infection, August 2013.  

Accessed online at http://www.fda.gov/ForConsumers/byAudience/ForPatientAdvocates/ 
 
HIVandAIDSActivities/ucm118915.htm on November  12, 2013.  First Databank and 

Red Book  contain both  NDCs  and drug names.  We used both sources to ensure we had a 

comprehensive list of  NDCs for HIV drugs. 

Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  5 
   
   
verify the date of death.22  If the dates of death did not match across the 
three sources, we took the latest date and used it in our analysis. 
Next, we calculated the total number of HIV drugs dispensed after the date 
of death.23   We then determined the number of beneficiaries and the total 
drug costs. We also calculated the difference between the date of service 
and the date of death. We determined the total number of drugs with dates 
of service that were within certain numbers of days after death and the 
total cost of these drugs.  
Lastly, we identified the pharmacies that dispensed each of these drugs.  
To determine the type of each pharmacy, we matched the National 
Provider Identifiers (NPIs) on the PDE record to the database of the 
National Council for Prescription Drug Programs.   This database contains 
descriptive information about each pharmacy, including the type of 
pharmacy (e.g., retail, long-term care, mail order).24   
Limitations 
We did not independently verify the accuracy of the PDE records, 
including the accuracy of the dates of service on the PDE records.     
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.   
____________________________________________________________ 
22 Accurint is a LexisNexis data repository that contains more than  20  billion records 
from  more than  10,000  data sources.   Accurints primary source for dates of death is  
SSAs Death Master File.  Accurint also contains death information from obituaries and 
State death records.  We matched beneficiaries Social Security Numbers, first and last 
names, and dates of  birth.  
23 For the purposes of this report, we considered a drug to  be one PDE record.  
24 For the purposes of this report, we used  the type that the pharmacy identified as its 
primary type. 
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  6 
   
   
FINDINGS 
Medicare paid for HIV drugs for over 150 deceased 

beneficiaries as a result of CMSs current practices 

In 2012, Medicare paid for 348 HIV drugs for 158 deceased beneficiaries. 
The total cost for these drugs was $292,381.25  For each of these drugs, the 
date of service on the PDE record was after the beneficiarys death. 
CMSs current practices allowed most of these payments to occur.   
Specifically, CMS has processing edits in place that should reject PDE 
records with dates of services that are more than 32 days after death.  As 
Table 1 shows, all but 3 of the 348 drugs were dispensed within 32 days 
after death. About half the HIV drugs were dispensed within 7 days after 
death. A total of 142 drugs were dispensed between 8 and 20 days after 
death, while 24 drugs were dispensed between 21 and 32 days after.    
 
Table 1: Number of Days After Death that the HIV Drugs Were Dispensed  
Number of Days After Death   Number of Drugs*  Total Drug Costs 
1 to 7 days  179  $151,433 
8 to 20 days  142  $120,314 
21 to 32 days  24  $18,183 
33 days or more   3  $2,450
     Total  348  $292,381 
*For the purposes of this report, we considered a drug to be one PDE record. 

Source:  OIG analysis of Part D data, 2014. 

 
CMSs practices allow payment for drugs that do not meet Medicare 
coverage requirements.  Part D covers only drugs that are prescribed for 
medically indicated purposes.  Drugs dispensed after death cannot be used 
for medically indicated purposes and therefore are not covered by Part D.   
According to CMS staff, the 32-day window is in place because some  
long-term-care pharmacies bill for Part D drugs once a month and 
inaccurately put this billing date, rather than the actual date of service, on 
the PDE record. 
 
____________________________________________________________ 
25 This  figure includes the amount paid  by sponsors,  by the Government, and on behalf of  
deceased beneficiaries. 
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  7 
   
   
Each of the 158 beneficiaries had between 1 and 6 drugs dispensed after 
the date of death; most beneficiaries had at least 2.  The most common 
drugs dispensed for deceased beneficiaries were Norvir and Truvada.26   
See the text box below for examples of HIV drugs dispensed for deceased  
beneficiaries. 
 
 
 
Examples of Drugs Dispensed After the Beneficiarys Death 
  and Paid for by Medicare 
 
    Medicare paid for three HIV drugs for a deceased beneficiary in 
Miami on two different dates after his death.  The drugs cost a total 
  of $7,160. 
 
    Medicare paid for six HIV drugs for a deceased beneficiary in  
Michigan. The drugs were ordered by two different prescribers 
  and cost $5,616. 
 
    Medicare paid for four HIV drugs dispensed in Pennsylvania after 
a beneficiarys death. These drugs cost $4,414. 
 
 
   Medicare paid for four HIV drugs for a deceased beneficiary in 
 
Florida. The drugs cost $3,452. 
 
 
 
Most of these drugs were dispensed by retail 
pharmacies 
Retail pharmacies dispensed 81 percent (283 of 348) of the HIV drugs for 
deceased beneficiaries.27  In total, 124 pharmacies dispensed drugs for 
deceased beneficiaries.  Of these, 106 were retail pharmacies, 8 were 
long-term-care pharmacies, and the remaining 10 were other types of 
pharmacies, such as clinics and mail-order pharmacies.  See Table 2. 
 
   
____________________________________________________________ 
26 Norvir and Truvada were also the most commonly dispensed HIV drugs among all   
Part D beneficiaries. 
 
27 Retail pharmacies dispensed  82 percent of all Part D drugs in 2009.  See OIG, Retail 

Pharmacies With Questionable Part D Billing, (OEI-02-09-00600), May 2012. 

Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  8 
   
   
   
  Table 2: Types of Pharmacies That Dispensed HIV Drugs for Deceased  
  Beneficiaries, 2012  
 
  Percentage of 
 
  Number of HIV  HIV Drugs 
  Number of   Drugs Dispensed  Dispensed 
  Pharmacy Type  
  Pharmacies  After Beneficiaries  After 
 
Deaths*   Beneficiaries 
 
  Deaths 
 
  Retail  106  283   81% 
 
 
Long-Term Care   8  31   9% 
 
 
  Clinic    4  16  5% 
 
  Mail Order   2  4   1% 
 
 
Specialty  1  4   1% 
 
 
  Other  3  10   3%
 
       Total  124  348   100% 
 
  *For the purposes of this report, we considered a drug to be one PDE record. 

  Source:  OIG analysis of Part D data, 2014. 

 
 
The 8 long-term-care pharmacies dispensed a total of 31 HIV drugs for 
deceased beneficiaries.  Of these, 20 drugs were dispensed within 7 days 
after death, 8 were dispensed between 8 and 20 days after death, and 
3 were dispensed between 21 and 31 days after death. The small number 
of these drugs attributed to long-term-care pharmacies indicates that the 
billing practices of these pharmacies do not result in many claims for HIV  
drugs within 32 days after a beneficiarys death.    
Furthermore, it is problematic if pharmacies are submitting their 
once-a-month billing date, rather than the actual date of service, on their 
PDE records. Sponsors are paid on the basis of PDE records, so it is 
important for these data to be accurate.  Also, sponsors, CMS, and OIG 
use PDE records to detect and prevent fraud, waste, and abuse, and poor 
data can hinder these efforts.  
 
   
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  9 
   
   
CONCLUSION AND RECOMMENDATION 
Our review focuses on HIV drugs; however, the findings have 
implications for all Part D drugs because Medicare processes PDE records 
for all drugs the same way.   The findings show that CMSs current practice 
of permitting Medicare to pay for drugs with a date of service that is after 
a beneficiarys date of death has resulted in Medicares inappropriately 
paying for drugs. Drugs for deceased beneficiaries are clearly not 
medically indicated, which is a requirement for Part D coverage. 
This review looked only at HIV drugs, which account for one-quarter of 
one percent of all Part D drugs in 2012.  A change in CMSs practice 
would affect all Part D drugs, not just HIV drugs.  Considering the 
enormous number of Part D drugs, a change in practice could result in 
significant cost savings for the program and for taxpayers. 
We recommend that CMS: 
Change Its Practice of Paying for Drugs That Have a Date of 
Service Within 32 Days After the Beneficiarys Death 
 
CMS should eliminate orif necessary for administrative processing 
issuesshorten the window in which it accepts PDE records after a 
beneficiarys death. Having no window or a short window would prevent 
inappropriate payments for drugs for deceased beneficiaries and lead to 
cost savings for the program and for taxpayers.  
   
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  10  
   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with our recommendation that it change its practice of 
paying for drugs that have a date of service within 32 days after a 
beneficiarys death.  CMS stated that it has had preliminary discussions 
with the industry to revisit the need for the 32-day window, which it had 
instituted because the date of service in some pharmacies reflects the date 
on which the prescription was billed, rather than the date on which the 
prescription was dispensed.  CMS further stated that it will continue 
discussions with the industry with the goal of reducing the window to the 
absolute minimum, taking into consideration current industry billing 
practices and systems constraints.   
CMS also stated that because many of the prescriptions identified by our 
study were filled at retail pharmacies, it will also evaluate the potential 
use of additional PDE fields in the current editing logic of evaluating the 
relationship of the date of service to the date of death.  Lastly, CMS 
stated that if OIG provides the PDE data for deceased beneficiaries, it will 
post these data for sponsors review and, if necessary, correction.  Any 
corrected or deleted PDE records would be considered in the reopening of  
the 2012 Part D reconciliation. (This reopening will adjust the final 
payment amounts that CMS made to sponsors for 2012.)  
We support CMSs efforts to address this issue.  As requested, we will 
provide CMS with a separate memorandum that includes the PDE records 
for deceased beneficiaries.  The full text of CMSs comments is provided 
in Appendix B. 
 
   
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  11  
   
   
APPENDIX A  
 HIV Drugs 
Brand Name   Generic Name  
Multi-Class Combination Products  
Atripla  efavirenz, emtricitabine, and tenofovir disoproxil fumarate  
 
Complera  emtricitabine, rilpivirine, and tenofovir disoproxil fumarate  
 
elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil 
Stribild 
  fumarate  
Nucleoside Reverse Transcriptase Inhibitors (NRTIs)  
Combivir  lamivudine and zidovudine 
 
Emtriva  emtricitabine, FTC 
 
Epivir  lamivudine, 3TC 
 
Epzicom  abacavir and lamivudine 
 
Retrovir  zidovudine, azidothymidine, AZT, ZDV  
 
Trizivir  abacavir, zidovudine, and lamivudine 
 
Truvada  tenofovir disoproxil fumarate and emtricitabine 
 
Videx EC  enteric coated didanosine, ddI EC  
 
Videx  didanosine, dideoxyinosine, ddI  
 
Viread  tenofovir disoproxil fumarate, TDF  
 
Zerit  stavudine, d4T  
 
Ziagen  abacavir sulfate, ABC 
 
Nonnucleoside Reverse Transcriptase Inhibitors (NNRTIs)  
Edurant  rilpivirine  
 
Intelence  etravirine 
 
Rescriptor  delavirdine, DLV 
 
Sustiva  efavirenz, EFV 
 
Viramune (Immediate 
nevirapine, NVP 
Release) 
 
Viramune XR (Extended  
nevirapine, NVP 
Release) 
 
Source:  FDA, Antiretroviral Drugs Used in the Treatment  of HIV Infection, August 2013.   
 
   
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  12  
   
   
HIV Drugs - Continued 
Brand Name   Generic Name  
Protease Inhibitors (PIs)  
Agenerase  amprenavir, APV (no longer marketed)  
 
Aptivus  tipranavir, TPV  
 
Crixivan  indinavir, IDV 
 
Fortovase  saquinavir (no longer marketed)  
 
Invirase  saquinavir mesylate, SQV  
 
Kaletra  lopinavir and ritonavir, LPV/RTV  
 
Lexiva  fosamprenavir calcium, FOS-APV 
 
Norvir  ritonavir, RTV  
 
Prezista  darunavir  
 
Reyataz  atazanavir sulfate, ATV  
 
Viracept  nelfinavir mesylate, NFV  
 
Fusion Inhibitors  
Fuzeon  enfuvirtide, T-20  
 
Entry Inhibitors - CCR5 Co-Receptor Antagonist  
Selzentry  maraviroc  
 
HIV Integrase Strand Transfer Inhibitors  
Isentress  raltegravir  
 
Source:  FDA, Antiretroviral Drugs Used in the Treatment  of HIV Infection, August 2013.   
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  13  
  APPENDIX 8 
Agency Comments 
DEPARTMENT OF I !EALTII & HUMAN SERVICES  Centers for Merhcare & Med!CiliO Serv1ces 
Atlmiuistrator 
Wnshmqton. OC 20201 
DATE: 
.SEP ZZ  2014 
TO:  Daniel R. Levinson 
Inspector Cieneral 
FROM: 	 Marily!> Tavenuer 
Administrator 
SUBJECT: 	 Office of Inspector General (O!G) Oral\ Rcpnrt: "Medicnre Paid fin HJV Drugs fi>r 
Deceased Beneficiaries" (OEI-02-11-00 172) 
The Centers lor Medicare & Medicaid Servin:s (CMS) appreciates the opportunity to review and 
comment on the ahove-rclerenced OIG dral\ report. The purpose oi' this report was to determine the 
extent to which Medicare Part D paid ((n human immunodeficiency virus (I-! IV) drugs Ji1r deceased 
heneficiaries in 2012. CMS appreciates OIG s concerns ahout Medicare paying li1r drugs and 
services after a hcnef1cimy has died. and has impkmented sall:guards to address these vulnerahilitics. 
For example. CMS has put into place processes to prevent payments made al\er a heneficlarys death 
and recover improper payments. Our response lO the OIG rcct>mmendation l(llfnws. 
OIG Recommendation 
OJG recommends that CMS change its practice or paying lor drugs that have a date orservice within 
32 days al\er the heneficiarys death. OIG stated thai CMS should climinntc or. if necessary l(>r 
administrative processing issues. shorten the window in which it accepts prescription drug event 
(PDE) data alkr a heneticiary's death. OIG helieves that having no window or a short window 
would prevent inappropriate payments li>r drugs l(lr deceased hene!lciaries and lead to cost-savings 
li1r the program and 1\>r taxpayers. 
CMS Response 
CMS concurs.  Arter reviewing this report. CMS has hml preliminary discussions with the industry to 
revisit the need llw a 32-day window, which was instituted because the date oi'service in some 
phannacies ret1ects the date the prescription was hilled, not the date the prescription was dispensed. 
CMS will continue discussions with the industry with a goal ofn.:ducing the margin to the ahsolute 
minimum given current industry hilling practices and systems constraints. CMS will <dso evaluate 
the potential usc of additional PDE lie ids in the current editing logic or evaluating the relationship nf 
the date of service to the date ofdeath since many of the pn.:scriptions were filled at retail 
pharmacies.  In addition. ifOIG can provide the PDE data. CMS will post the data to the PDE 
website lor sponsor review and ifnecessm-y. correction.  Any corrected or clcktccl !'DEs would be 
considered in the 2012 Part D reopening. 
Thank you 1()1 the opportunity to review and comment on the drali OICi report. 
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  14   
   
 
ACKNOWLEDGMENTS 
This report was prepared under the direction of Jodi Nudelman, Regional 

Inspector General for Evaluation and Inspections in the New  York regional 

office, and Nancy Harrison and Meridith Seife, Deputy Regional 

Inspectors General.  

Miriam  Anderson served as the team leader for this study.  Other Office of 

Evaluation and Inspections staff from the New York regional office who 

conducted the study include Jenell Clarke-Whyte and Jason Kwong.  

Central office staff who provided support include Eddie Baker, Jr.; 

Mandy Brooks; Kevin Farber; David Graf; Meghan Kearns; and 

Christine Moritz. 
 
Medicare Paid for HIV Drugs for Deceased Beneficiaries (OEI-02-11-00172)  15  
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.