Last week Medicare issued an intermediate sanction notice to Aetna Insurance Company prohibiting any marketing or enrollment of new beneficiaries into their national Part D prescription drug stand-alone plan and their 25 Medicare Advantage Prescription Drug plans (MA-PDs) as of April 21, 2010.
This sanction is in response to growing provider and beneficiary complaints of not being able to access their medications and having unnecessary obstacles and illegitimate denials for drugs for which they are entitled.
The Centers for Medicare and Medicaid Services says the sanctions will stay in place until Aetna adequately demonstrates they have corrected these problems and that they will not re-occur. Aetna currently has 400,000 beneficiaries enrolled in their MA-PD plans, and 600,000 enrolled in their stand-alone PDP plan.
Some of the obligations Aetna plans have failed to fulfill for their Medicare beneficiary enrollees as listed in CMS’ press release include:
- Failing to meet Medicare’s transition requirements by ensuring that existing beneficiaries were able to continue to receive drugs they had been receiving in 2009 that were not on the plans’ formularies in 2010;
- Improperly processing coverage determinations and expedited appeal requests in cases where delays would jeopardize the life or health of the enrollee;
- Applying prior authorization (PA) and step therapy (ST) drug requirements that had not been approved by Medicare; and
- Failing to take timely and proper steps to ensure that enrollees are eligible for the Part D low-income subsidy (LIS).
If the situation fails to improve for Aetna’s enrollees, CMS has warned that Aetna Insurance Company could incur penalties and even termination of their Medicare contracts.
In addition to Aetna, CHA has reports of potential problems with WellCare Part D plans – such as encountering prior authorization (PA) requests for certain drugs where in the past there had been none. If you or your clients encounter any such problems with WellCare or Aetna plans, please contact us and let us know.
July 10th, 2010 at 2:39 pm
below is a letter i wrote to speaker pelosi. i would like to talk with you further on this matter. i can be reached at 415-776-3133. it could prove helpful to all your readers.
June 11, 2010
The Honorable Speaker of the House of Representative
Nancy Pelosi
San Francisco, California – 8th District
Dear Speaker of the House of Representatives:
Walgreen’s Drug Store state “Federal and State statutes prohibit persons enrolled in a publicly funded healthcare program to participate in this program.” (Attachment)
Both Wal-Mart and Target do not prohibit persons enrolled in a publicly funded healthcare program to participate in such programs.
Is the statement, which Walgreen’s makes, “Federal and State statutes prohibit persons enrolled in a publicly funded healthcare program to participate in this program”, correct?
Numerous vendors of Medicare Part D and various Medicare support groups make this or very similar such statement: “Remember you should NEVER buy your generics using your Part D Plan. Get them for $4 a month at many big box pharmacies. This will keep you OUT of the donut hole longer each year. Even though your co-pay is $8 for a generic on your drug plan, they ding your plan $20, $30 or more toward reaching the donut hole. Watch your statements from your drug plan and make sure the pharmacy does not make a claim you have asked them not to make”.
If so, please provide me with the federal laws/statutes that support Walgreen’s statement and actions.
If not stated in federal laws/statutes what can be done to get Walgreen to correct this blatant false statement?
Thank you,
Warren Lambert
965 Sutter Street
Unit 117
San Francisco, CA 94109
415-776-3133
warrenlambert@sbcglobal.net
Signed and dated June 11, 2010 at 4:24 PM (Pacific Time)
July 12th, 2010 at 2:53 pm
Hi Mr. Lambert,
Thank you for your post and sharing the letter you wrote to Representative Pelosi. I suggest you contact your local Health Insurance Counseling and Advocacy Program (HICAP) with this question as well and you can show them the attachment you referred to in your email (it doesn’t show up in the blog comment post). HICAP provides free counseling and advocacy on Medicare and such issues/questions you pose here about the $4 prescription program offered by some pharmacies.
Here’s a list of all the HICAP offices by county.
Thank you again for contacting us and for bringing your concerns to our Representatives.
Warm regards,
Karen