GAO-06-78R Medicare Prescription Drug Card Program

United States Government Accountability Office

Washington, DC 20548 

October 28, 2005 

The Honorable Henry A. Waxman 

Ranking Minority Member 

Committee on Government Reform 

House of Representatives 

Subject: Medicare: CMS’s Implementation and Oversight of the Medicare Prescription 

Drug Discount Card and Transitional Assistance Program 

Dear Mr. Waxman: 

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) added 

a prescription drug benefit to the Medicare program, to become effective January 1, 2006.1

 To 

assist Medicare beneficiaries with their prescription drug costs until the new benefit becomes 

available, the MMA also required the establishment of a temporary program, the Medicare 

Prescription Drug Discount Card and Transitional Assistance Program, which began in June 

2004.2

 The drug card program is designed to offer Medicare beneficiaries access to discounts 

off the retail price of prescription drugs. All Medicare beneficiaries, except those receiving 

Medicaid drug coverage, are eligible to enroll in the drug card program. Certain low-income 

beneficiaries without other drug coverage qualify for an additional benefit, a transitional 

assistance (TA) subsidy,3

 that can be applied toward the cost of drugs covered under the drug 

card program. 

The Centers for Medicare & Medicaid Services (CMS)—the agency within the Department of 

Health and Human Services that administers the Medicare and Medicaid programs—

administers and oversees the drug card program. The drug cards themselves are offered and 

managed by private organizations, known as drug card sponsors. There are different types of 

drug cards. General drug cards are available to all eligible beneficiaries living in a card’s 

 

1

Pub. L. No. 108-173, §101, 117 Stat. 2066, 2071, 2072. 

2

Pub. L. No. 108-173, §101, 117 Stat. 2066, 2071, 2131. Throughout this report, we refer to the Medicare 

Drug Discount Card and Transitional Assistance Program as the drug card program. Beneficiaries can 

enroll in the drug card program through December 2005. Beneficiaries can use their drug cards until 

the effective date of their enrollment in a Medicare prescription drug plan or until May 15, 2006, 

whichever comes first. 

3

For beneficiaries who qualify for TA, the program offers a subsidy of up to $600 per year toward the 

cost of covered drugs. To qualify for TA, a beneficiary must have (1) an income at or below 135 

percent of the federal poverty level and (2) with certain exceptions, not have other prescription drug 

coverage through Medicaid, an employer-sponsored group health insurance program, an individual 

health insurance policy, TRICARE (the Department of Defense health care program for active-duty 

personnel, retirees, and their dependents), or the Federal Employees Health Benefits Program. TA 

funds available to beneficiaries in 2004 and 2005 can be used until the effective date of their enrollment 

in a Medicare prescription drug plan or until May 15, 2006, whichever comes first. 
2 GAO-06-78R Medicare Prescription Drug Card Program 

 

service area; there are both national and regional general cards.4 Exclusive and special 

endorsement drug cards are available to specific beneficiary groups.5

 Some drug card 

sponsors offer more than one drug card. 

You asked us to examine CMS’s implementation and oversight of the temporary drug card 

program. Specifically, we reviewed (1) the processes that CMS used to solicit, evaluate, and 

approve drug card sponsors; and (2) the processes that CMS uses to oversee drug card 

sponsors and the problems identified as a result of CMS oversight.6

 

To address these objectives, we focused our work on general drug cards; our work did not 

include exclusive or special endorsement cards. We interviewed CMS officials, staff from 6 

CMS contractors that assist with key program oversight activities, and staff from 8 of 32 

general drug card sponsors.7

 The drug card sponsors we interviewed represented a mix of 

national and regional cards; varied in terms of total enrollment size, TA enrollment size, and 

number of beneficiary complaints received by CMS; reflected different organization types 

(for example, pharmacy benefit managers,8

 managed care organizations, and health insurers); 

and included drug card sponsors whose applications were approved by CMS and those 

whose applications to offer drug cards were initially denied, but later approved. We also 

reviewed relevant CMS, CMS contractor, and drug card sponsor documents, such as CMS 

guidance, CMS contractor reports, and drug card sponsor applications. We targeted CMS’s 

oversight of elements of five key program areas for more focused review—drug prices, 

sponsors’ pharmacy networks, sponsor-provided beneficiary information, TA, and beneficiary 

complaints and grievances. We selected these areas based on their likelihood to influence 

beneficiaries’ enrollment decisions and access to drugs, as well as their potential to pose 

problems or weaknesses for the program. When feasible, we validated the information CMS 

officials told us by reviewing program documents and interviewing officials from CMS 

contractors and drug card sponsors. We conducted our work from April 2005 through 

October 2005 in accordance with generally accepted government auditing standards. 

We briefed your staff on the information contained in this report on September 23, 2005. As 

discussed with your staff at that time, we agreed to issue this report, which officially 

transmits the briefing slides (see enc. I) and expands on the information provided at the 

briefing. 

4

National cards provide beneficiaries access to discounts at pharmacies nationwide, while regional 

cards offer discounts at pharmacies within a smaller geographic area—an entire state at a minimum. 

5

Exclusive cards are cards that Medicare managed care plans offer only to their plan enrollees. (Some 

managed care plans offer general cards open to all eligible beneficiaries, not just those enrolled in their 

plan.) Special endorsement cards serve residents of long-term care facilities such as skilled nursing 

facilities; U.S. territory residents; and American Indians and Alaskan Natives who use Indian Health 

Service, Indian Tribe and Tribal Organization, and Urban Indian Organization pharmacies.

6

We are conducting other work related to this topic. See Medicare: CMS’s Beneficiary Education and 

Outreach Efforts for the Medicare Prescription Drug Discount Card and Transitional Assistance 

Program, GAO-06-139R (Washington, D.C.: forthcoming). We also plan to issue a report in 2005 on 

sponsors’ processes related to the drug card program. 

7

Included in the 32 sponsoring organizations are affiliated organizations, such as 11 individual Blue 

Cross and Blue Shield entities that are counted as one organization. 

8

Pharmacy benefit managers manage prescription drug benefits for third-party payers, such as 

employer-sponsored health plans and other health insurers.
3 GAO-06-78R Medicare Prescription Drug Card Program 

 

Background 

CMS implemented the drug card program within a 6-month time frame. The MMA was 

enacted on December 8, 2003. The following week, CMS published an interim final rule that 

outlined the drug card program, including the requirements that organizations had to meet to 

become drug card sponsors.9

 Interested organizations had to submit applications to CMS by 

January 30, 2004. Organizations that CMS approved as drug card sponsors could begin 

enrolling beneficiaries on May 3, 2004. The drug card program took effect on June 1, 2004. 

Organizations had to meet certain requirements in order to be approved by CMS as drug card 

sponsors. For example, a drug card sponsor had to be a nongovernmental organization doing 

business in the United States, be financially stable and reputable, have at least 3 years of 

private-sector experience in pharmacy benefit management, and serve at least 1 million 

covered lives under a similar pharmacy benefit program. Drug card sponsors also had to 

agree to manage the enrollment and TA processes for their cards, offer customer service and 

beneficiary grievance programs, provide program information to beneficiaries, operate a tollfree customer call center, and report data about their drug cards—such as drug price and 

utilization data—to CMS. 

Drug card sponsors also had to demonstrate their ability to meet requirements regarding drug 

prices and beneficiaries’ access to pharmacies. One requirement of the program is that drug 

card sponsors must offer a negotiated price10 for at least one drug in each of over 200 drug 

classes that CMS identified as being commonly used by Medicare beneficiaries.11 According 

to CMS, nearly all prescription drugs that can be purchased at retail pharmacies are eligible 

to be covered by sponsors’ drug cards.12 The MMA refers to 9 classes of drugs that drug card 

sponsors are not allowed to cover through their drug cards; the excluded classes include 

barbiturates and benzodiazepines, among others. While drug card sponsors may change the 

prices charged to beneficiaries, they must report all price increases to CMS and explain the 

rationale for price increases not attributable to published sources of information such as the 

Average Wholesale Price (AWP) of the drug.13 They must also contract with a sufficient 

9

Medicare Program; Medicare Prescription Drug Discount Card; Interim Rule and Notice, 68 Fed. Reg. 

69840 (2003). 

10The MMA specified that drug card sponsors shall provide access to “negotiated prices” on the drugs 

they cover. CMS regulations define negotiated price as the discounted price that takes into account 

negotiated price concessions such as discounts, rebates, and direct or indirect subsidies or 

remunerations. Drug card sponsors are required to obtain rebates, discounts, or other price 

concessions from drug manufacturers and to pass on a share of these concessions to card enrollees; 

neither the MMA nor CMS’s regulations specify any minimum amount that must be passed on to 

enrollees. 

11Drugs that possess similar chemical structures and similar therapeutic effects are grouped into 

classes. Most drugs within a class produce similar benefits, side effects, adverse reactions, and 

interactions with other drugs and substances.

12Covered drugs include prescription drugs, certain vaccines, insulin, and some medical supplies 

associated with the injection of insulin. 

13AWP is a list price that a manufacturer suggests wholesalers charge pharmacies. 
4 GAO-06-78R Medicare Prescription Drug Card Program 

 

number of pharmacies to ensure that their pharmacy networks meet the program’s network 

access requirements.14

 

After reviewing applications from interested organizations, CMS approved all but 1 general 

drug card.15 Two potential drug card sponsors withdrew their applications to offer a general 

drug card. The 71 approved general drug cards included 39 national drug cards and 32 

regional drug cards. Because 5 approved national drug cards were never marketed, 66 

general drug cards enrolled beneficiaries. These 66 active general drug cards are sponsored 

by 32 different organizations. Many general drug cards are sponsored by pharmacy benefit 

managers, managed care organizations, or health insurers. As of August 2005, there were 

nearly 3.8 million general drug card enrollees; about 44 percent were enrolled in both a drug 

card and TA, while about 56 percent were enrolled in a drug card only. About 87 percent of 

general drug card enrollees were enrolled in national drug cards, and about 13 percent were 

enrolled in regional drug cards.16

CMS has provided guidance to drug card sponsors through several means. The agency has 

conducted periodic conference calls available to all sponsors and has shared guidance 

through e-mail bulletins and “Questions and Answers” posted on the CMS Web site. It also 

has provided written guidance on topics such as sponsors’ outreach activities and the drug 

card data that sponsors must report to CMS. In addition, CMS assigned staff to serve as the 

point of contact for each drug card sponsor to provide individual guidance and assistance. 

Results in Brief 

The processes CMS used to solicit, evaluate, and approve general drug card applications 

were geared to the 6-month time frame between the enactment of the MMA and the 

mandated start date for the drug card program. This included the type of solicitation CMS 

used, the design of the application, and the application evaluation and approval process. 

• CMS used a noncompetitive solicitation process in which all qualified organizations could 

participate in the program. CMS officials told us they took this approach to encourage 

participation in the program, facilitate communication with and among potential drug 

card sponsors, and avoid the need to develop weighted criteria to evaluate the 

applications—which CMS officials said would have been required if a competitive 

solicitation was used. 

• CMS developed the application for drug card sponsors before all of the program’s 

operational guidelines had been completed. As a result, CMS officials said that openended questions were used to learn more about and evaluate potential sponsors’ 

capabilities and for other reasons. 

14By regulation, in urban areas, at least 90 percent of a card’s enrollees must live within 2 miles of a 

contracted network pharmacy; in suburban areas, at least 90 percent must live within 5 miles of a 

contracted network pharmacy; and in rural areas, at least 70 percent must live within 15 miles of a 

contracted network pharmacy. These access standards are based on those used in the TRICARE Retail 

Pharmacy program, which provides prescription services for Department of Defense beneficiaries 

through a network of retail pharmacies. 

15CMS denied one applicant due to what it considered a failure to respond substantively to the 

application requirements. 

16As of August 2005, CMS reported 6.4 million enrollees across all types of drug cards. 
5 GAO-06-78R Medicare Prescription Drug Card Program 

• Based on its initial review of applicants, CMS approved only those that provided all of the 

information requested in the application. Initially denied applicants whose applications 

were missing minor information were allowed to provide the missing information through 

a redetermination process; those whose applications were missing significant information 

were allowed to appeal the denial through a reconsideration process. CMS announced its 

initial list of approved general drug card sponsors on March 25, 2004; that list did not 

include sponsors that had not completed the redetermination and reconsideration 

processes. The last sponsor was approved on May 7, 2004. 

CMS’s oversight of drug card sponsors has identified and corrected some problems, but has 

had some limitations with respect to the timeliness of oversight activities and the guidance 

provided to sponsors. CMS uses multiple methods to monitor drug card sponsors. CMS 

investigates the complaints it receives directly from 1-800-MEDICARE17 and other sources, 

and collects information about the complaints reported to sponsors, known as “grievances.” 

CMS has collected other data from drug card sponsors regularly, including drug price and 

pharmacy information that it published on its Price Compare Web site,18 as well as 

information on manufacturer and pharmacy price concessions. CMS also uses contractors to 

assist with oversight activities, including conducting financial audits of drug card sponsors 

and analyzing sponsor-reported price data. With respect to CMS’s oversight, we reviewed five 

key program areas: drug prices, sponsors’ pharmacy networks, sponsor-provided beneficiary 

information, TA, and beneficiary complaints and grievances. 

Drug Prices

• Early in the program, CMS identified problems such as inconsistencies in sponsors’ 

reported unit prices for non-pill prescriptions—such as creams, powders, and 

sprays—and delays in drug card sponsors’ reporting of data. CMS officials told us 

that, as a result, they worked with sponsors to standardize the reporting of non-pill 

prices, did not post some sponsors’ data on the Price Compare Web site, and took 

compliance actions against sponsors with reporting delays. 

• Work to determine if non-TA enrollees have been inappropriately charged more than 

the maximum drug price reported on the Price Compare Web site began in June 2005; 

results are expected in November 2005. 

• CMS finalized guidance on how drug card sponsors should report data on price 

concessions from manufacturers and pharmacies in November 2004, about 5 months 

after the program began. According to CMS, as of August 2005, the overall quality of 

that data remained questionable, with problems such as outliers and missing data. 

 

171-800-MEDICARE is a CMS-administered nationwide toll-free telephone help line that beneficiaries, 

their families, and other members of the public can call to ask questions about program eligibility, 

enrollment, and benefits.

18This Web site, with information for beneficiaries on available drug cards, was part of the 

“Prescription Drug and Other Assistance Programs” tool located at www.medicare.gov—a tool to help 

beneficiaries determine their eligibility for the drug card program, decide whether to enroll in the 

program, and select a drug card. CMS deactivated the component of the Web site with information 

about drug prices on September 30, 2005. 
6 GAO-06-78R Medicare Prescription Drug Card Program 

Sponsors’ Pharmacy Networks

• CMS officials told us that they have followed up on complaints received from 

beneficiaries and pharmacists about the accuracy of the pharmacy participation 

information displayed on the Price Compare Web site. In reviewing reported 

problems, CMS found that most of the problems were due to pharmacies being 

unaware that they were participating in a drug card sponsor’s network; sometimes 

pharmacies were not actually participating in a sponsor’s network even though they 

were listed on the Price Compare Web site. CMS officials told us that they worked 

with drug card sponsors to improve pharmacy awareness about program 

participation. When warranted, CMS corrected the pharmacy participation 

information on the Price Compare Web site. 

• A CMS contractor also surveyed a sample of pharmacies in February 2005 to 

determine if they were participating in sponsors’ pharmacy networks, in accordance 

with what was shown on the Price Compare Web site. According to CMS officials, 

preliminary survey results as of August 2005 showed some disagreement between 

pharmacies’ responses and the Price Compare Web site information, with the rate of 

disagreement higher for some drug card sponsors and in three states (North Dakota, 

Iowa, and Missouri). Although this survey did not assess the reason for the 

disagreement, in its comments on a draft of this report, CMS stated that the 

disagreement was likely due to problems with pharmacies’ knowledge about program 

participation, rather than errors on the Web site. CMS officials said they began 

following up with sponsors identified as problematic in summer 2005. In its 

comments, CMS reported that it had conducted compliance conference calls with 

those sponsors and had encouraged them to re-educate their network pharmacies. 

Sponsor-provided Beneficiary Information

• A CMS contractor conducted a limited retrospective review of drug card sponsors’ 

marketing materials in March 2005. Two pre-enrollment packets were requested by 

phone from each of six general drug card sponsors. All the packets were 

noncompliant with program requirements. Most packets were missing materials 

required by CMS and some materials had not been previously approved for 

distribution by the CMS contractor. The contractor never received several requested 

packets. CMS officials said that they worked with the drug card sponsors reviewed to 

resolve these problems. 

• CMS’s primary method for monitoring information provided by drug card sponsor call 

centers was a contractor-conducted study in which callers posing as beneficiary 

caregivers used different scenarios to test customer service representatives’ 

responses to questions. CMS officials told us about several problems, including the 

unavailability of representatives for non-English speaking callers, the unavailability of 

representatives able to respond to callers using telecommunications for the deaf, 

inappropriate handling of beneficiary complaints about pharmacies (in which callers 

were told to contact the pharmacies themselves rather than file a grievance with the 

sponsor), and customer service representatives’ confusion about enrollment fees if 

their call centers were handling calls about multiple drug cards. Most of the 

contractors’ calls were conducted from June through December 2004. CMS officials 

said that sponsors were contacted during this period if there were problems such as a 

wrong call center telephone number or a call center that was closed during the hours 
7 GAO-06-78R Medicare Prescription Drug Card Program 

it claimed to be open. CMS officials told us that their follow-up with sponsors for the 

other identified call center issues began in summer 2005. 

Transitional Assistance

• Financial audits of sponsors conducted by a CMS contractor revealed that 

$1.3 million in TA funds were inappropriately used by drug card sponsors to pay for 

excluded drugs, which sponsors are required to repay. While CMS had provided 

general guidance on excluded drug classes on several previous occasions, it did not 

issue a comprehensive list of excluded drugs until November 2004. 

• Financial audits also revealed that several sponsors had allowed beneficiaries to 

receive subsidies that exceeded the subsidy of up to $600 per year. CMS officials 

attributed this to issues such as problems when beneficiaries transferred among 

cards. Drug card sponsors are required to repay excess payments. 

Beneficiary Complaints and Grievances

• Most complaints reported to CMS and grievances reported to sponsors related to 

enrollment and disenrollment issues. For example, some beneficiaries complained to 

CMS about delays in receiving drug cards from drug card sponsors. CMS staff told us 

they worked with beneficiaries and drug card sponsors to resolve complaints. 

As a result of its oversight efforts, as of August 2005, CMS had taken 23 compliance actions 

against 15 drug card sponsors, most often in the form of warning letters or corrective action 

plans. 

Agency Comments 

We provided a draft of this report for comment to the Administrator of CMS, and we received 

written comments. (See enc. II.) 

CMS commented that the draft report did not paint a full picture of the depth and breadth of 

the agency’s monitoring and oversight activities conducted relative to the Medicare drug card 

program. As our draft report discussed, we examined CMS’s oversight of elements of five key 

program areas: drug prices, sponsors’ pharmacy networks, drug card sponsor-provided 

beneficiary information, TA, and beneficiary complaints and grievances. We targeted these 

specific program areas based on their likelihood to influence beneficiaries’ enrollment 

decisions and access to drugs. Furthermore, because these targeted areas represented 

fundamental components of the drug card program, any problems or weaknesses posed a 

threat to the overall integrity of the program. 

In commenting on our finding that there was a lack of reliable data on price concessions, 

CMS agreed that there were significant data quality issues relative to the information 

submitted by drug card sponsors. CMS noted, however, that despite these concerns, the 

initial data, as well as information from other sources, including some external to CMS, 

suggested that drug card sponsors are passing through to beneficiaries a substantial portion 

of their negotiated rebates, discounts, and other price concessions. CMS also stated that it 

has worked to resolve the data quality issues and that most price concession data 

submissions are now accurate. Our work focused on CMS’s oversight of the price concession 

data reported by sponsors, not on the magnitude of price concessions passed on to 

beneficiaries. As noted in the draft report, the overall quality of that data as of August 2005 
8 GAO-06-78R Medicare Prescription Drug Card Program 

was questionable; we have not assessed or verified changes in the data’s quality since that 

time. However, both CMS’s comments and our findings in this area highlight the importance 

of CMS oversight of sponsor-reported data. 

In response to our finding that CMS’s oversight of drug card sponsors has had some 

limitations with respect to the timeliness of oversight activities and the guidance provided to 

sponsors, CMS noted that it implemented the drug card program and instituted a wide range 

of oversight activities for the program, which is temporary, within a short period of time. In 

the draft report, we acknowledged the limited time between the December 2003 enactment of 

the MMA (which established the drug card program) and the June 2004 implementation of the 

program, as well as the temporary nature of the program. We also acknowledged various 

oversight activities that CMS noted were conducted. However, as discussed in the draft 

report, we identified some limitations of CMS’s oversight of sponsors. For example, we noted 

that in February 2005, a CMS contractor surveyed a sample of pharmacies to determine if 

they were participating in sponsors’ pharmacy networks in accordance with what was shown 

on the Price Compare Web site. For some sponsors, there were high levels of disagreement 

between pharmacies and the Web site. As noted in the draft report, CMS officials said they 

began working with those sponsors in summer 2005. In commenting specifically on our 

findings about the pharmacy network issue, CMS provided further detail about the oversight 

activities that it has conducted. 

In response to our finding that TA funds were used to pay for excluded drugs on some 

occasions and that some beneficiaries received subsidies that exceeded the subsidy of up to 

$600 per year, CMS commented that the inappropriate payments were small in relation to the 

total services delivered over the duration of the program. CMS further stated that it was the 

responsibility of drug card sponsors to identify the drugs in the excluded classes and to 

ensure that these drugs were not covered under the program. CMS added that in July 2004 it 

had provided sponsors with a list of drugs for two of the excluded drug classes. As noted in 

the draft report, financial audits conducted by a CMS contractor for 15 drug cards revealed 

that the sponsors of all 15 cards had incorrectly used TA funds to cover excluded drugs. It 

was not until November 2004 that a comprehensive list of drugs covering all of the excluded 

classes was provided by CMS. CMS is responsible for ensuring that no program monies are 

inappropriately spent. 

With regard to our statements about problems related to information provided by drug card 

sponsors’ call centers, in its comments, CMS provided some additional details on related 

oversight activities that it has conducted. CMS noted, for example, that the CMS contractorconducted study using test calls to call centers found that for Spanish language callers, there 

were problems obtaining information in Spanish 20 percent of the time; 80 percent of the 

time, information was provided in Spanish. The findings from CMS’s oversight of sponsors’ 

call centers highlight the need for monitoring of sponsor-provided beneficiary information 

and, when needed, corrective action. 

In its comments, CMS also noted that the agency has learned many valuable lessons as a 

result of its experience with the drug card program, and that those lessons will inform its 

future efforts as it moves forward with the implementation of the Medicare prescription drug 

benefit that is to become effective in 2006. 

CMS also provided technical comments, which we incorporated as appropriate.
9 GAO-06-78R Medicare Prescription Drug Card Program 

- - - - - 

As agreed with your office, unless you publicly announce the contents of this report earlier, 

we plan no further distribution of it until 30 days from the date of this report. At that time, we

will send copies to the Administrator of CMS and interested congressional committees. The 

report will also be available on GAO’s home page at http://www.gao.gov. 

 

If you or your staff have any questions or need additional information, please contact me at

(202) 512-7114 or kanofm@gao.gov. Contact points for our Offices of Congressional Relations 

and Public Affairs may be found on the last page of this report. Key contributors are listed in 

enclosure III. 

Sincerely yours, 

Marjorie Kanof

Managing Director, Health Care 

Enclosures – 3 
Enclosure I Enclosure I

10 GAO-06-78R Medicare Prescription Drug Card Program

GAO Briefing 

1

CMS’s Implementation and Oversight of 

the Medicare Prescription Drug Discount 

Card and Transitional Assistance Program

Briefing for the Staff of 

The Honorable Henry A. Waxman

Ranking Minority Member

House Committee on Government Reform

(Updated)
Enclosure I Enclosure I

11 GAO-06-78R Medicare Prescription Drug Card Program 

2

Briefing Overview

• Introduction

• Objectives

• Scope and Methodology

• Background

• Findings
Enclosure I Enclosure I

12 GAO-06-78R Medicare Prescription Drug Card Program 

3

Introduction 

Medicare Drug Benefit

The Medicare Prescription Drug, Improvement and 

Modernization Act of 2003 (MMA) established:

• A temporary program, the Medicare Prescription Drug

Discount Card and Transitional Assistance (TA) Program,

which began in June 2004.

a

• A Medicare prescription drug benefit, known as Medicare 

Part D, which begins in January 2006.

a Throughout these slides, we refer to this program as the drug card program.
Enclosure I Enclosure I

13 GAO-06-78R Medicare Prescription Drug Card Program 

4

Introduction 

Medicare Prescription Drug Cards

• The Centers for Medicare & Medicaid Services (CMS)

administers and oversees the drug card program.

• All Medicare beneficiaries, except those receiving

Medicaid drug coverage, are eligible to enroll in the drug 

card program, which provides access to discounts off the

retail price of prescription drugs.

• TA offers eligible low-income beneficiaries without other

drug coverage up to $600 per year for prescription drugs 

covered under the drug card program.

• Drug cards are offered and managed by private

organizations, known as drug card sponsors. Drug card

sponsors also manage TA for eligible beneficiaries.
Enclosure I Enclosure I

14 GAO-06-78R Medicare Prescription Drug Card Program 

5

Objectives

1. To review the processes CMS used to solicit, evaluate, and

approve drug card sponsors.

2. To review the processes CMS uses to oversee drug card 

sponsors and the problems identified as a result of CMS

oversight.
Enclosure I Enclosure I

15 GAO-06-78R Medicare Prescription Drug Card Program 

6

Scope and Methodology

Scope

• Our work focused on general drug cards—cards offered on a 

national or regional basis to all eligible Medicare beneficiaries 

living in the cards’ service areas.

• Our work did not include exclusive cards, which are cards 

that Medicare managed care plans offer only to their plan

enrollees, or special endorsement cards, which serve 

residents of long-term care facilities such as skilled nursing 

facilities; residents of U.S. territories; and American Indians 

and Alaskan Natives who use Indian Health Service, Indian

Tribe and Tribal Organization, and Urban Indian Organization 

pharmacies.
Enclosure I Enclosure I

16 GAO-06-78R Medicare Prescription Drug Card Program 

7

Scope and Methodology 

Methods

• Our methods included:

• Interviews with CMS officials.

• Interviews with staff of six contractors assisting CMS with

key program oversight activities.

• Interviews with staff from eight drug card sponsors.

• Reviews of relevant documents.

• Reviews of selected program areas.

• We performed our work in accordance with generally 

accepted government auditing standards from April 2005

through October 2005.
Enclosure I Enclosure I

17 GAO-06-78R Medicare Prescription Drug Card Program 

8

Background

Drug Card Program Implementation Timeline

Source: GAO analysis.
Enclosure I Enclosure I

18 GAO-06-78R Medicare Prescription Drug Card Program 

9

Background

Drug Card Sponsor Program Requirements

• Drug card sponsors had to demonstrate to CMS their ability 

to meet program requirements, including, for example:

• Relevant organizational experience, including financial

stability and at least 3 years of private-sector experience

in pharmacy benefit management.

• Beneficiary access to pharmacies.

• Beneficiary access to discounts for covered drugs.

• Drug card sponsors are allowed to offer multiple drug cards,

which are differentiated by factors such as the geographic

locations in which they are offered and the level of discounts

provided.
Enclosure I Enclosure I

19 GAO-06-78R Medicare Prescription Drug Card Program 

10

Background

Approved General Drug Cards

• CMS approved 71 general drug cards, including:

• 39 national cards.

• 32 regional cards.

• Five approved national cards were never marketed; there are

66 active general drug cards offered by 32 sponsoring 

organizations.a

aIncluded in the 32 sponsoring organizations are affiliated organizations, such as individual Blue 

Cross and Blue Shield entities that are counted as one organization.
Enclosure I Enclosure I

20 GAO-06-78R Medicare Prescription Drug Card Program 

11

Background

Types of Sponsoring Organizations

Active general cards by type of sponsoring organization, as of

August 2005.

15

21

30

Total general 

cards

32

18

12

Regional

cards

34

13

3

18

National

cards

Total 66

Other 2

Health insurer/managed care organization

Pharmacy benefit manager

Type of sponsoring organization

Source: GAO analysis of CMS data and drug card sponsor information.

Note: Table does not reflect five approved national cards that were never marketed. “Other” includes 

an information technology company, a medical products company, and a claims processor, among

others.
Enclosure I Enclosure I

21 GAO-06-78R Medicare Prescription Drug Card Program 

12

Background

General Drug Card and TA Enrollment

General drug card and TA enrollment as of August 2005.

Source: GAO analysis of CMS data.

Note: As of August 2005, CMS reported 6.4 million enrollees across all drug card types.

Number Percentage Number Percentage

Total 1,646,479 43.6 2,129,238 56.4 3,775,717

Regional 323,020 66.2 164,659 33.8 487,679

National 1,323,459 40.3 1,964,579 59.7 3,288,038

Total 

general 

drug card

enrollment

Drug card only 

enrollment

Drug card and

TA enrollment

General drug

card type
Enclosure I Enclosure I

22 GAO-06-78R Medicare Prescription Drug Card Program 

13

Background

CMS Guidance to Drug Card Sponsors

• CMS issued guidance to drug card sponsors using a number

of mechanisms, including: 

• Periodic conference calls open to all sponsors.

• Bulletins distributed via e-mail.

• Electronic posting of “Questions and Answers.”

• Other written guidance, such as information and outreach

guidelines.

• CMS assigned staff to serve as a point of contact for each

drug card sponsor to provide individual guidance and 

assistance.
Enclosure I Enclosure I

23 GAO-06-78R Medicare Prescription Drug Card Program 

14

Summary of Findings

• The processes CMS used to solicit, evaluate, and approve

drug card sponsors were influenced by the 6-month 

implementation time frame.

• CMS’s oversight of sponsors has identified and corrected 

some program problems, but has had some limitations with 

respect to the timeliness of oversight activities and the 

guidance provided to sponsors.
Enclosure I Enclosure I

24 GAO-06-78R Medicare Prescription Drug Card Program 

15

Objective 1

The Processes CMS Used to Solicit, Evaluate, 

and Approve Drug Card Sponsors Were 

Influenced by the 6-Month Implementation 

Time Frame
Enclosure I Enclosure I

25 GAO-06-78R Medicare Prescription Drug Card Program 

16

Drug Card Sponsor Selection

Overview

The 6-month implementation time frame influenced the:

• Solicitation type.

• Application design.

• Application evaluation and approval process.
Enclosure I Enclosure I

26 GAO-06-78R Medicare Prescription Drug Card Program 

17

Drug Card Sponsor Selection

Noncompetitive Solicitation 

CMS used a noncompetitive solicitation process in which all 

organizations meeting qualification requirements could

participate in the program. CMS officials told us they took this

approach to:

• Meet the 6-month implementation time frame.

• Encourage participation, given the uncertainty of industry

interest in the program.

• Facilitate communication among and between drug card

sponsor applicants and CMS.

• Avoid the need to develop weighted criteria to evaluate 

applications.
Enclosure I Enclosure I

27 GAO-06-78R Medicare Prescription Drug Card Program 

18

Drug Card Sponsor Selection

Open-Ended Questions

• CMS used open-ended questions in the application it used to

evaluate potential sponsors. 

• CMS officials said that they took this approach because the

short implementation time frame required that the application

be designed before some of the program’s operational

guidelines had been developed.
Enclosure I Enclosure I

28 GAO-06-78R Medicare Prescription Drug Card Program 

19

Drug Card Sponsor Selection

Open-Ended Questions (cont.)

• CMS officials told us that the open-ended questions allowed 

them to learn about and evaluate applicants’ capabilities by

requiring detailed and descriptive responses.

• CMS officials said this would not have been possible using 

closed-ended questions that would have prompted, for 

example, a “yes” or “no” response. Each applicant was 

asked to describe, for example, how:

• Its administrative infrastructure would interact with CMS.

• It would manage the TA benefit.
Enclosure I Enclosure I

29 GAO-06-78R Medicare Prescription Drug Card Program 

20

Drug Card Sponsor Selection

Information Provided in the Application 

• CMS officials told us that they did not use all of the 

information provided in the application to evaluate potential

sponsors; they used some of this information to gain a better 

understanding of the industry. For example, they solicited

information to better understand:

• The frequency of price increases for drugs most 

commonly used by Medicare beneficiaries.

• Educational efforts used by the industry pertaining to

generic substitution.
Enclosure I Enclosure I

30 GAO-06-78R Medicare Prescription Drug Card Program 

21

Drug Card Sponsor Selection

Some Application Questions Problematic

CMS officials said that some of the application questions

were problematic for applicants to answer due to:

• Short time frame—For example, sponsors’ contractual

relationships with drug manufacturers and pharmacies had 

not all been finalized, so reporting expected price

concessions for beneficiaries was problematic for some 

sponsors.

• Lack of clarity about information to be provided—For

example, applicants were asked to provide information on a

few classes of drugs, such as antacids, for which only overthe-counter medications were available. Over-the-counter 

medications are not covered under the drug card program.
Enclosure I Enclosure I

31 GAO-06-78R Medicare Prescription Drug Card Program 

22

Drug Card Sponsor Selection

Applicants’ Attestations 

• CMS officials told us, and our review of the application 

confirmed, that they often relied on applicants’ attestations 

about their abilities to meet certain program requirements. 

For example:

• Applicants were required to attest that they had contracts

in place with drug manufacturers and pharmacies, but 

copies of executed contracts were not required to be

submitted to CMS.

• Applicants were required to attest that they would be 

ready to enroll beneficiaries and provide discounts and 

TA by May 3, 2004.
Enclosure I Enclosure I

32 GAO-06-78R Medicare Prescription Drug Card Program 

23

Drug Card Sponsor Selection 

Application Evaluation and Approval Process

• Based on its initial evaluation of applicants, CMS approved 

only those that provided all of the information requested in

the application.

• For applicants that CMS initially denied:

• Those with applications missing minor information were

allowed to provide the missing information through a 

redetermination process.

• Those with applications missing significant information 

could appeal the denial through a reconsideration

process.
Enclosure I Enclosure I

33 GAO-06-78R Medicare Prescription Drug Card Program 

24

Drug Card Sponsor Selection 

Application Redetermination and Reconsideration

• Twelve potential sponsors (representing 18 general drug cards) 

supplied new information through the redetermination process.

• Four potential sponsors (representing 11 general drug cards) 

with applications denied due to missing significant information all

notified CMS of the intent to appeal and requested a hearing

through the reconsideration process outlined in the interim final

rule for the drug card program.

• At the first hearing, the CMS hearing officer ruled that new

information submitted by an applicant must be considered. This 

prompted CMS to allow other potential sponsors missing 

significant information to submit that information without going

through a formal hearing.
Enclosure I Enclosure I

34 GAO-06-78R Medicare Prescription Drug Card Program 

25

Drug Card Sponsor Selection 

Drug Card Sponsor Approval

• CMS announced its initial list of approved general drug card

sponsors on March 25, 2004. 

• The initial list did not include sponsors that had not

completed the redetermination and reconsideration

processes. 

• The final sponsor’s application was approved on May 7, 

2004.
Enclosure I Enclosure I

35 GAO-06-78R Medicare Prescription Drug Card Program 

26

Drug Card Sponsor Selection 

Application Approval Results

• CMS approved applications for

71 general drug cards.

• CMS denied one application.

• Two applications were

withdrawn by the sponsoring 

organizations.

Application Approval Results, 

by Number of Drug Cards
Enclosure I Enclosure I

36 GAO-06-78R Medicare Prescription Drug Card Program 

27

Objective 2

CMS’s Oversight of Sponsors Has Identified and

Corrected Some Program Problems, but Has Had Some

Limitations with Respect to the Timeliness of Oversight 

Activities and the Guidance Provided to Sponsors
Enclosure I Enclosure I

37 GAO-06-78R Medicare Prescription Drug Card Program 

28

CMS’s Oversight Approach

Multiple Methods

• Reviews of complaints and grievances.

• Analyses of sponsor-reported data.

• Use of contractors to help perform oversight.

Methods CMS uses to monitor sponsors include:
Enclosure I Enclosure I

38 GAO-06-78R Medicare Prescription Drug Card Program 

29

CMS’s Oversight Approach

Complaints and Grievances

• CMS’s regional offices investigate beneficiary complaints.

CMS uses a Web-based tool to track and manage complaints 

it receives through:

• 1-800-MEDICARE.

• www.medicare.gov.

• Written correspondence from beneficiaries.

• Congressional correspondence.

• CMS requires sponsors to collect, track, resolve, and report 

beneficiary concerns reported to sponsors, known as

“grievances.”
Enclosure I Enclosure I

39 GAO-06-78R Medicare Prescription Drug Card Program 

30

CMS’s Oversight Approach 

Data Sponsors Report to CMS

Source: GAO summary of CMS information.

As-needed • Material modifications to a sponsor’s drug card

• Price concessions from manufacturers and pharmacies,

amount of concessions passed on to beneficiaries

• Number of dispensed prescriptions

Quarterly

• Number of grievances reported to sponsors

• Prescription utilization

Monthly

• Drug prices and participating pharmacy information for

CMS’s Price Compare Web sitea

Weekly

Examples of type of information

Frequency of

reporting

aThis Web site, located at www.medicare.gov, includes information for beneficiaries on available 

drug cards. CMS deactivated the component of the Web site with information about drug prices 

on September 30, 2005.
Enclosure I Enclosure I

40 GAO-06-78R Medicare Prescription Drug Card Program 

31

CMS’s Oversight Approach 

Contractor-Conducted Oversight Activities

Source: GAO summary of CMS and CMS contractor information.

Collection, review, and posting of information for CMS’s Price 

Compare Web site

DestinationRx

Management of beneficiary requests for reconsideration of TA and

eligibility decisions

MAXIMUS

Navigant Identification of errors in price data; analysis of price changes

Consulting, Inc.

Analysis of drug price data; audits of sponsor policies and

procedures; referrals of potential fraud cases

IntegriGuard

Analysis of sponsor self-reported data; development of metrics to

measure sponsor performance and identify potential problems; 

development of sponsor report cards

Booz Allen

Hamilton

Reviews of sponsors’ beneficiary outreach materials; test calls to

sponsor call centers; pharmacy participation survey

BearingPoint

Contractor Key oversight activities
Enclosure I Enclosure I

41 GAO-06-78R Medicare Prescription Drug Card Program 

32

CMS’s Oversight of Selected Program Areas

Key Program Areas

We focused on CMS oversight of elements of the following key 

program areas:

• Drug prices.

• Sponsors’ pharmacy networks.

• Beneficiary information (sponsor-provided).

• Transitional assistance.

• Complaints and grievances.

CMS’s oversight has resulted in various formal compliance 

actions against sponsors.
Enclosure I Enclosure I

42 GAO-06-78R Medicare Prescription Drug Card Program 

33

CMS’s Oversight of Selected Program Areas

Drug Prices

• Sponsors’ weekly price files are reviewed for outliers and other data

concerns.

• CMS officials told us that early-reported data were sometimes problematic 

due to:

• Incorrectly placed decimal points.

• Inconsistent unit pricing of non-pill prescriptions (e.g., creams, sprays).

• Delays in sponsors’ reporting.

• CMS officials said that they took steps in response:

• Some sponsors’ data were not posted on the Price Compare Web site.

• Warning letters were issued, which improved reporting.

• In June 2005, a CMS contractor began work to see if non-TA enrollees had

been inappropriately charged more than the maximum price posted on the

Web site. Results are expected in November 2005.
Enclosure I Enclosure I

43 GAO-06-78R Medicare Prescription Drug Card Program 

34

CMS’s Oversight of Selected Program Areas

Drug Prices (cont.)

• The MMA required sponsors to pass price concessions from 

manufacturers to beneficiaries, and CMS requires sponsors to

report price concessions from both manufacturers and pharmacies

to CMS.

• CMS guidance about sponsors’ reporting requirements, including 

the reporting of price concessions, was finalized in November 2004.

• Some sponsors said the guidance lacked clarity.

• According to CMS, as of August 2005, the overall quality of price 

concession data was questionable, with problems such as outliers

and missing data. CMS officials said they were working with

sponsors to resolve the problems.
Enclosure I Enclosure I

44 GAO-06-78R Medicare Prescription Drug Card Program 

35

CMS’s Oversight of Selected Program Areas

Sponsors’ Pharmacy Networks

• According to CMS, some beneficiaries complained that pharmacies listed

on the Price Compare Web site were not accepting their cards; some

pharmacies complained that they were incorrectly listed as participating 

in a sponsor’s network. 

• CMS found that most of the problems were due to pharmacies being

unaware that they were participating in a sponsor’s network.

• CMS found that sometimes pharmacies were not actually

participating in a sponsor’s network.

• CMS worked with sponsors to improve pharmacies’ awareness 

about their participation in the program; when warranted, Web site 

information was corrected.

• Some participating pharmacies complained they were not listed on the 

Price Compare Web site. CMS officials told us that they worked to 

improve the accuracy of information in the national pharmacy database 

they used for the Web site.
Enclosure I Enclosure I

45 GAO-06-78R Medicare Prescription Drug Card Program 

36

CMS’s Oversight of Selected Program Areas

Sponsors’ Pharmacy Networks (cont.)

In February 2005, a CMS contractor began a survey of a sample of

2,055 pharmacies listed on the Price Compare Web site to determine 

whether they were participating in sponsors’ pharmacy networks, as

shown on the Price Compare Web site. 

• Surveys were sent to sampled pharmacies listed as

participating in at least one general drug card.

• Pharmacy staff were asked which drug cards they accepted.

• Their responses were compared to information on the Price 

Compare Web site, to determine if there was agreement 

between pharmacies and the Web site about pharmacies’ 

participation in sponsors’ networks.
Enclosure I Enclosure I

46 GAO-06-78R Medicare Prescription Drug Card Program 

37

CMS’s Oversight of Selected Program Areas

Sponsors’ Pharmacy Networks (cont.)

CMS officials told us that preliminary results, as of August 2005, 

showed that pharmacies’ responses sometimes did not agree with 

what was shown on the Price Compare Web site.

• Nationally, there was about 80 percent agreement (and 20 

percent disagreement) between pharmacies and the sponsor

network information on the Price Compare Web site.

• North Dakota, Iowa, and Missouri pharmacies, which were

oversampled due to a disproportionate number of complaints,

had lower levels of agreement—between 63 and 74 percent.

• CMS identified some sponsors with particularly low levels of

agreement between pharmacies and the Price Compare Web 

site information, and began following up with them during

summer 2005.
Enclosure I Enclosure I

47 GAO-06-78R Medicare Prescription Drug Card Program 

38

CMS’s Oversight of Selected Program Areas

Beneficiary Information

• Sponsors’ marketing materials were prospectively reviewed and 

approved by a CMS contractor prior to distribution to beneficiaries.

• Reviewers compared materials to criteria in CMS guidance and found 

common errors (such as missing forms) and incorporated their findings 

into sponsor training sessions. 

• CMS staff examined some of the materials reviewed by the contractor

and found that reviewers generally followed CMS guidance.

• CMS staff and several sponsors reported cases of inconsistency among 

the contractor’s reviewers; CMS officials said that the contractor took

steps to improve consistency.
Enclosure I Enclosure I

48 GAO-06-78R Medicare Prescription Drug Card Program 

39

CMS’s Oversight of Selected Program Areas

Beneficiary Information (cont.)

• In March 2005, the same contractor conducted a limited 

retrospective review to determine if materials sent to beneficiaries

had been approved. 

• Two pre-enrollment packets were requested by phone from

each of six general card sponsors.

• Reviewers noted whether packets had all required materials and if 

all materials had been prospectively approved.

• All packets were noncompliant. Most packets were missing 

required materials, and some materials lacked required changes

or had not been approved.

• The contractor never received several requested packets.

• CMS officials told us they worked with the sponsors reviewed to

resolve identified problems.
Enclosure I Enclosure I

49 GAO-06-78R Medicare Prescription Drug Card Program 

40

CMS’s Oversight of Selected Program Areas

Beneficiary Information (cont.)

• A contractor study using test calls was CMS’s primary method for

monitoring information provided by sponsor call centers.

• Most calls were conducted from June through December 2004.

• Callers posed as beneficiary caregivers.

• Different scenarios were used to test customer service 

representatives’ responses.

• CMS officials told us about several problems, such as:

• Unavailability of representatives for non-English speaking 

callers and callers using telecommunications for the deaf.

• Inappropriate handling of complaints about pharmacies.

• Representatives’ confusion about enrollment fees.

• CMS officials said they began contacting sponsors about these

problems in summer 2005.
Enclosure I Enclosure I

50 GAO-06-78R Medicare Prescription Drug Card Program 

41

CMS’s Oversight of Selected Program Areas

Transitional Assistance

• Results from financial audits of 15 drug cards revealed that the

sponsors of all 15 cards had incorrectly used TA funds to cover

excluded drugs,a totaling $1.3 million in incorrect TA payments. 

• CMS provided guidance on excluded drugs on several occasions

but did not provide a specific list of excluded drugs for all drug 

classes until November 2004, about 5 months after the program 

began.

• Sponsors are required to repay CMS incorrect payments identified

by CMS or through their own self-reporting.

aThe MMA refers to nine drug classes, such as barbiturates and benzodiazepines, that sponsors

were required to exclude from their drug cards.
Enclosure I Enclosure I

51 GAO-06-78R Medicare Prescription Drug Card Program 

42

CMS’s Oversight of Selected Program Areas

Transitional Assistance (cont.)

• Results from the 15 financial audits revealed that the sponsors of

five drug cards had allowed beneficiaries to receive subsidies that

exceeded the subsidy of up to $600 per year.

• CMS officials attributed this to issues such as problems when

beneficiaries transferred among drug cards.

• Sponsors are required to repay excess payments identified by CMS

or through their own self-reporting.
Enclosure I Enclosure I

52 GAO-06-78R Medicare Prescription Drug Card Program 

43

CMS’s Oversight of Selected Program Areas

Complaints Received by CMS

• Nearly 11,000 complaints 

received by CMS about general 

drug cards.

a

• Most complaints related to 

enrollment and disenrollment.

• Some drug cards had less than 1

complaint per 1,000 enrollees; 

others had 15 or more

complaints per 1,000 enrollees.

aReflects complaints received as of August 31, 

2005.

Complaints Received by CMS, by Type
Enclosure I Enclosure I

53 GAO-06-78R Medicare Prescription Drug Card Program 

44

CMS’s Oversight of Selected Program Areas

Grievances Reported by Sponsors

• Over 15,000 grievances reported 

by general drug card sponsors to 

CMS.a 

• Most grievances related to

enrollment and disenrollment.

• Some drug cards had no reported 

grievances; others had 50 or more

grievances per 1,000 enrollees.

• Sponsors are required to report the

number of grievances in general

categories and if they are resolved. They do not report information on 

the causes of grievances.

aReflects grievances reported as of September 9, 2005.

Grievances Reported by Sponsors, by Type
Enclosure I Enclosure I

54 GAO-06-78R Medicare Prescription Drug Card Program 

45

CMS’s Oversight of Selected Program Areas

Formal Compliance Actions

As of August 2005, CMS had taken multiple actions against sponsors.

Total 23

Contract termination 0 Not applicable (no terminations)

1 Multiple compliance failures C c ivil monetary penalty

2 Improper payments to pharmacists, failure to grant audit access Enrol b lment freeze 

Improper inducements to pharmacists and beneficiaries; display

of a Canadian pharmacy on a drug card Web page

Corrective action plans 10

Sponsors did not report data for display on the Price Compare 

Web site

Warning letter 9

Sponsor threatened to withdraw other lines of business from

pharmacies unless they accepted its drug card

Educational call 1

Example reasons for action

Number of

actions Typ a e of action

Source: GAO summary of CMS information. aCMS took compliance actions against 15 sponsors; for 5 sponsors, CMS took more than one action. bFor one sponsor, a freeze was implemented. For the other sponsor, CMS proposed an enrollment freeze, but 

later withdrew the proposal because the sponsor corrected its compliance problem. cCMS proposed a civil monetary penalty for one sponsor; as of September 2005, the penalty was under appeal.
Enclosure II Enclosure II

55 GAO-06-78R Medicare Prescription Drug Card Program

Comments from the Centers for Medicare & Medicaid Services
Enclosure II Enclosure II 

56 GAO-06-78R Medicare Prescription Drug Card Program 
Enclosure II Enclosure II 

57 GAO-06-78R Medicare Prescription Drug Card Program 
Enclosure II Enclosure II 

58 GAO-06-78R Medicare Prescription Drug Card Program 
Enclosure II Enclosure II 

59 GAO-06-78R Medicare Prescription Drug Card Program 
Enclosure II Enclosure II 

60 GAO-06-78R Medicare Prescription Drug Card Program 
Enclosure II Enclosure II 

61 GAO-06-78R Medicare Prescription Drug Card Program 
Enclosure II Enclosure II 

62 GAO-06-78R Medicare Prescription Drug Card Program 
Enclosure III Enclosure III 

63 GAO-06-78R Medicare Prescription Drug Card Program

GAO Contact and Staff Acknowledgments 

GAO Contact Marjorie Kanof (202) 512-7114 or kanofm@gao.gov

Acknowledgments In addition to the person named above, key contributors to this report 

 were Debra Draper, Assistant Director; Lori Achman; Jennie Apter; 

 Robin Burke; Meredith Kimball; Patricia Roy; and Syeda Uddin. 

(290449) 
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