Another Part D Provider Sanctioned by Medicare

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by Mary Jane Stern

Just the other day I started writing a blog about AdvantraRx our Medicare Part D provider for 2009 and 2010.  This year, 2010, they reclassified a drug my husband takes as a Step Therapy (ST) drug and would not honor his prescription unless he took another medication or paid for the drug himself.

And WOW, on April 9, 2010, an article in the WSJ (Wall Street Journal) by Avery Johnson And Dinah Wisenberg Brin titled, Aetna Hit by Medicare Compliance Problems answered my questions of what’s going on with our Part D Provider, AdvantraRx.  But in particular, what’s going on with Part D Providers in general?

If you remember, in March CMS terminated Fox Insurance Company because of non-compliance with the Part D program.

According to the news release from CMS here’s what Aetna did:

“Medicare issued the intermediate sanction because the plan has failed to fully meet its obligations to Medicare beneficiaries.   More specifically those obligations include, but are not limited to:

● 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).

Now, after reading the letter sent by CMS to Aetna, AdvantraRx imposed a Drug Utilization Management (D.U.M.) requirement on this drug that had not previously been required. During 2009 this drug was a “non-preferred brand” with only the co-pay being higher, and no other restrictions.

After speaking with two different customer service representatives, they both had a cold attitude of “take the drug we want you to take or pay yourself.” However, they should have offered a 30 day supply until necessary appeals could be made or time to discuss the changes with the doctor.

It’s extremely concerning how one individual, without knowing a person’s health condition or being a medical doctor, can impose requirements that could jeopardize the life, health and/or safety of an enrollee.

According to the WSJ article “Medicare plans overall are experiencing cuts in government reimbursement this year, and payments to insurers are expected to be flat in 2011, so insurers have been trimming benefits and taking other steps to maintain margins.”

Here’s a breakdown of health insurance executive compensation for 2008, I’m sure 2009 will be out in a few more months:

REMEMBER – CMS encourages plan members who may have concerns with their Part D coverage to contact 1-800-MEDICARE (1-800-633-4227) or the state health insurance assistance program (SHIP) to help get them resolved.

There are two things I need to do (1) contact CMS and state my concerns about AdvantraRx and (2) Find another Part D provider during open enrollment later this year.