Community Pharmacists Getting Closure in Fox Insurance-ProCare PBM Saga Over Medicare Part D Claims


By Kevin Schweers

When well-intentioned good-government groups decry “lobbyists” and “special interests,” one thing they probably don’t have in mind is the long-running saga of community pharmacists waiting many months for reimbursement while Fox Insurance Company and pharmacy benefit manager (PBM) ProCare sparred over who should pay for indisputably legitimate Medicare Part D claims.

Sadly, without the intervention of the National Community Pharmacists Association (NCPA) and its allies in Congress, who knows how many of these claims would remain unpaid today. Originating as far back as February 2010, they amount to $13 million and counting. (Note: If your pharmacy happens to hold any unpaid claims, know that Nov. 30, 2010 is the final deadline by which claims must be submitted to LI-NET in order to receive payment.)

For anyone who’s been following this yarn from day one, it may seem reminiscent of the 2004 Tom Hanks film The Terminal. In it, a hapless man (Hanks) flees a fictional, war-torn Eastern European country and is subjected to a sequence of seemingly limitless bureaucratic procedures in JFK International Airport to determine who “owns” his case as he pursues safe harbor in America or elsewhere.

Fortunately, once NCPA officials informed U.S. Senate Finance Committee Chairman Max Baucus (D-Mont.) and Ranking Member Charles Grassley (R-Iowa) the apparent foot-dragging involved in paying these claims, they immediately sprung into action, and $13 million was paid in July.

We’ve featured these developments in NCPA’s members-only update: e-News weekly. In case you’ve missed those articles, we’ve posted the details below as the Nov. 30 deadline is fast approaching. At the risk of noting the obvious, practically any portion of the $13 million in paid claims is not a bad return on NCPA annual dues of $295.

Fox Insurance Claims Update:

The Centers for Medicare & Medicaid Services has informed NCPA that any unpaid FOX Insurance Claims for March 10, 11, 12, and later should be submitted to LI-Net, the Medicare Limited Income Newly Eligible Transition Program. Any claims up to 11:59 p.m. on March 9 should go to ProCare, FOX’s PBM. CMS terminated FOX from the CMS Part D program on March 9, 2010.

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