News Releases

NCPA Reacts to Medicare Corrective Action Plan for Aetna

by NCPA | Feb 04, 2015

Urges Additional Steps to Avoid Repeating Problems in 2016

Alexandria, Va. Feb. 4, 2015 - The Corrective Action Plan (CAP) that federal Medicare officials have requested of Aetna is an important first step and the Centers for Medicare & Medicaid Services (CMS) should go one further by issuing new guidance to all Medicare Part D prescription drug plan sponsors to prevent a 2016 repeat of the Aetna problems experienced in early 2015, the National Community Pharmacists Association (NCPA) said today.

Seniors, caregivers and pharmacists have encountered a number of problems this year with the glitch-plagued Aetna/Coventry Medicare Part D drug plans. Most notably, during the open enrollment period Aetna and the Medicare Plan Finder website inaccurately advertised that Aetna plan networks included pharmacies that were in fact out-of-network. CMS has confirmed approximately 400,000 beneficiaries may have been affected by this problem, many of whom have had difficulty having their prescriptions filled at their chosen pharmacy, which they believed was in-network.

"Beneficiaries relied upon erroneous posted information to choose their Part D plan and, unfortunately, Aetna/Coventry did not act in a timely enough manner to try to remediate the situation," said NCPA CEO B. Douglas Hoey, RPh, MBA. "The corrective action plan requested by CMS is a welcome first step. But we believe more must be done to avoid reliving next January what has been a very disruptive experience for seniors, caregivers and community pharmacists. We encourage CMS to take additional steps to mitigate similar problems in the future."

In its letter, CMS concludes that Aetna failed to comply with its statutory obligation to invite and allow participation of any willing pharmacy in the standard pharmacy network of its Part D plans. The agency said the focus of the CAP must be to bring the insurer into compliance with any willing pharmacy requirements as soon as possible for both the 2015 and 2016 plan years. Specifically, CMS also clarified that the CAP must include a set of network pharmacy standard terms and conditions for all of Aetna’s 2015 Part D plans that include a provision clearly identifying the plan(s) to which the terms and conditions apply. In the event that Aetna does not demonstrate timely compliance, CMS also indicated that it reserves the right to impose additional enforcement actions, such as suspending marketing and enrollment, imposing a monetary fine or the issuance of a contract termination notice.

In addition, NCPA recommends that CMS implement the following policies through guidance or regulation for a smoother transition in early 2016:

  • Allow informed beneficiary choices by stipulating that, at least 15 days prior to beneficiary Open Enrollment, plans have accurate pharmacy network participation information loaded into Plan Finder for beneficiaries and that pharmacies be notified if they will be out-of-network for the upcoming plan year.

  • Require plan sponsors to document compliance with "any willing pharmacy" obligations that allow all pharmacies the opportunity to participate in a plan’s standard network.

  • Provide plan sponsors a specific date by which they must offer their standard terms and conditions to any willing pharmacy. Ideally this deadline would come in early June when plan sponsors must submit bids to CMS, so that pharmacies can consider and respond to the terms well before the Plan Finder website goes live for the upcoming plan year.

  • Ensure consistent terminology to describe pharmacy networks by all plans. For example, in the Aetna case, confusion for pharmacies was compounded because Aetna counterintuitively called its broadest pharmacy network "Premier Preferred," while it called a narrower one "Standard." Similarly perplexing naming convention tactics with the Part D plan names that beneficiaries were considering during open enrollment further added to patient confusion in choosing a plan.

NCPA has also called for a Congressional hearing to examine this situation and discuss potential solutions to avoid future disruptions in beneficiary care. Beneficiaries who have been impacted can switch drug plans by calling 1-800-Medicare to take advantage of a special enrollment period.

The 2015 problems recall patient access issues experienced by other Medicare beneficiaries and help further illustrate the need for an effective, more comprehensive "any willing pharmacy" policy.

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The National Community Pharmacists Association (NCPA®) represents the interests of America's community pharmacists, including the owners of nearly 23,000 independent community pharmacies. Together they represent an $88.8 billion health care marketplace, dispense nearly 40% of all retail prescriptions, and employ more than 300,000 individuals, including over 62,000 pharmacists. To learn more, go to www.ncpanet.org, visit facebook.com/commpharmacy, or follow NCPA on Twitter @Commpharmacy.