The Med Diva

An insider's guide to Medicare Part D and more

Medicare Drops the Ball on New Mail-Order Pharmacy Rule for Part D Members

Medicare drops the ball on seniors

I recently posted two articles about a new Medicare Part D rule that affected beneficiaries who get their medications delivered on a regular basis from a mail-order pharmacy. The rule, which went into effect on January 1, required all pharmacies with home delivery services to get direct consent from Part D plan members before shipping each and every medication.

Today I have some good news to share: The enlightened folks at Medicare have decided that — surprise, surprise — this new rule did not work as intended. Last week, much to our relief, the Centers for Medicare & Medicaid Services (CMS) rescinded the rule.

Full details are still pending, but as of now, you do not need to give your pharmacy permission to ship the medications you regularly receive by mail. It’s probably not quite as simple as this, so if I hear more, I’ll let you know.

If you’re still not familiar with the rule I’m referring to, I’m not surprised. Medicare did a very poor job communicating the details of the rule with Part D plans and beneficiaries.

In a nutshell, the rule required pharmacies to get consent from the plan member (by phone or online) every time the member’s doctor submitted a new prescription or a refill on an existing prescription was ready to be shipped. If the pharmacy didn’t get the member’s consent, it could not ship the medication. No consent, no medication. Period.

As soon as I heard about this rule back in November, I knew it was a recipe for disaster. This rule, I thought, had the potential to create a serious safety issue for seniors and other Medicare beneficiaries. I was right.

Without guidance and communications from Medicare, Part D plans and their members were left in the dark. I tried to provide clear information about the rule for our plan members, but even I found it too complicated to fully understand and explain.

By the first week of March – just two months after the rule went into effect – hundreds of thousands of prescriptions were being held up in mail-order pharmacies throughout the country. Medicare beneficiaries didn’t receive the medications they needed because they didn’t know about the rule or understand how to provide consent. I’m sure many people were very worried and confused when their medications didn’t arrive in the mail on time as expected.

So as I let out a huge sigh of relief, I have something to say to CMS: You really screwed up on this one. By not providing clear communications to Part D plans and members about this complex rule, you created a major safety issue for seniors. You didn’t think it through and consider all the logistics and implications. You dropped the ball and left it up to Part D plans and pharmacies to put it back in play, even though you didn’t provide the rules of the game.


New Government Rules Affect Medicare Part D Mail-Order Pharmacy Services

Medicare Part D

A few weeks ago I posted important news about a big change that affects Medicare beneficiaries who get their medications from a Medicare Part D mail-order pharmacy. Based on feedback I have received, many Medicare Part D plan members still do not understand how this rule affects them. That means a lot of people are probably wondering why they haven’t received their medications.

So let me try to help and explain this new rule again:

As of January 1, 2014, you must give your mail-order pharmacy permission to dispense and ship every prescription.

For example:
• If your doctor calls in a prescription, sends an e-prescription, or sends a prescription by fax to your mail-order pharmacy, you still need to give the pharmacy permission to process that order. This rule applies whether your doctor is ordering a NEW prescription or is RENEWING a prescription that has expired.

• If you normally get refills every three months, you will need to give the pharmacy permission every three months for every medication.

• If you were previously enrolled in an automatic refill service, you are no longer able to use this type of service.* Under this new rule, your prescription drugs can no longer be automatically refilled and shipped to your home.

NOTE: The pharmacy will not be able to ship your medication until you provide permission and confirm that you want to get the order.

When Do I Need to Give My Permission?

If you place your own order: If you order your own new prescriptions or refills by phone, mail, or pharmacy website, you DO NOT have to provide any additional permission. The fact that you ordered the medication yourself is considered “providing permission” under this new Medicare rule.

If your doctor places the order: If your doctor calls in a new prescription or faxes a prescription to the pharmacy, you will need to provide permission to confirm that you want this medication.

If you need refills: If you have a refill that is waiting to be shipped, you must give your consent and confirm that you want your prescription to be refilled.*

How Do I Give Permission?

Depending on your mail-order pharmacy, there are several ways to provide consent when your pharmacy receives an order from your doctor or has a refill waiting to be shipped:

Online: If your mail-order pharmacy has a website, you may be able to go online to provide consent for refills, new prescriptions, or renewed prescriptions.

Email: Your pharmacy may send you an email with a link to a website where you can provide permission.

Phone: Your pharmacy may provide a phone number to call or use an automated phone message that asks you to give your consent over the phone.

In any case, the pharmacy will need to get your consent before shipping every order, so make sure they have your most current phone number or email address. Until you give permission, your order will not be processed and your medication will not be shipped.

If you are currently using a Medicare Part D mail-order pharmacy, you should have received information by mail, phone, or email regarding this change in service. If you haven’t received any information about this new Medicare rule, you should contact your plan or your mail-order pharmacy to confirm that they have your correct contact information on file.

Why Did Medicare Establish This Rule?

Many mail-order or home delivery pharmacies provide a convenient refill service that automatically ships prescription drugs when the customer is about to run out of medication. Unfortunately, some Medicare Part D plans never checked to find out if their customers still wanted or needed their drugs. The automatic refill service was simply put on auto-pilot, so to speak, and would send the medication to the person’s home every three months or so.

Once the drug was sent in the mail, the customer was stuck with it — even if he or she was no longer taking the medication. This waste was costing Medicare a lot of money. So the Centers for Medicare & Medicaid Services (CMS) decided to take action and create this new rule.

*If you are in a Medicare Part D plan that is sponsored by your current or former employer, some rules about automatic refills may not apply to you. Contact your plan or mail-order pharmacy for additional information about refills.

Combating fraud and abuse in the Medicare Prescription Drug Program

This is great news from CMS that I wanted to share with my readers.

Changes to Automatic Refill Services Under Medicare Part D Mail-Order Pharmacies in 2014

Part D Mail-Order Pharmacy

If you are a Medicare beneficiary who gets your medications from a Medicare Part D mail-order pharmacy, I have some important information that may affect your services starting in January 2014.

Many mail-order or home delivery pharmacies provide an automatic refill service that will automatically ship your prescription drugs when you are about to run out of medication. For example, if you have a 90-day prescription for a certain medication, the mail-order pharmacy will automatically ship a refill when you have about two weeks of medication left. This service is very convenient, especially if you take several medications, and it has always been one of the main advantages of using a mail-order pharmacy.

Unfortunately, in recent years some prescription drug plans weren’t periodically checking to find out if their customers still wanted or needed their drugs. The automatic refill service was simply put on auto-pilot, so to speak, and would send the medication to the person’s home every three months or so. Once you received that drug in the mail, you were stuck with it whether you still needed it or not.

Since pharmacies are not allowed to restock prescription drugs that are sent by mail, some automatic delivery services were creating a lot of waste and unnecessary additional costs for people with Medicare and the Part D program in general. So the Centers for Medicare & Medicaid Services (CMS) decided to take action.

Starting January 1, 2014, mail-order pharmacies (and retail pharmacies with home delivery service) must get your approval before they will ship or deliver a new prescription or refill. That means that if you normally get refills every three months, you will need to provide your consent every three months for every medication. Even if your doctor calls in a new prescription, you will still need to provide your authorization. The pharmacy will not be able to ship your medication until you confirm you want to get the order.

Depending on your mail-order pharmacy, you may have to go to a website or reply to an email to provide authorization, or the pharmacy may call you on the phone to get your consent. Either way, the pharmacy will need to reach you before shipping every order, so make sure they have your most current phone number or email address. Until someone from the pharmacy reaches you and gets your consent, the pharmacy will not be able to process the order and ship your medication.

Keep in mind that if you place an order for medication yourself — whether by phone, mail, or online — you will not have to provide additional consent when the medication is ready to be shipped. Also note that this new policy won’t affect refill reminder programs at retail pharmacies when you go in person to pick up the medication. It also won’t apply to long-term care pharmacies that give out and deliver prescription drugs.

If you are currently using a Medicare Part D mail-order pharmacy, you should be receiving a notice by mail or email regarding this change in service. The notice should provide information that is specific to your plan and your pharmacy. If you don’t receive a notice by the first week of January, you should contact the mail-order pharmacy to confirm that your correct contact information is on file.

It’s no trick or treat: Kids get high on drugs, not sugar

 HalloIt’s sad but true: There’s a very good chance that at least one young person you know is abusing prescription and/or over-the-counter drugs to get high.

 According to the most recent National Survey on Drug Use and Health (September 2010), teens and young adults abuse prescription drugs more than any illicit drug except marijuana, and the main reason is because they are readily available.Many teens get high on drugs that they obtain from friends, who in turn are getting these drugs by going through their parents’ or grandparents’ medicine cabinets. What’s even scarier: Kids as young as 12 and 13 years old report that prescription drugs are their drugs of choice! So much for the good old-fashion sugar high from hoarding all the Halloween candy.

What kind of prescription drugs are teens abusing?

1. Painkillers
Painkillers are drugs commonly prescribed for pain and include: Vicodin, Tylenol with Codeine, OxyContin, and Percocet.
2. Depressants
Depressants (aka downers, sedatives, or tranquilizers) are prescribed to treat a variety of health conditions including anxiety and panic attacks, tension, severe stress reactions, and sleep disorders. They include: Klonopin, Nembutal, Soma, Ambien, Valium, and Xanax.
3. Stimulants
Stimulants, or uppers, are usually prescribed for attention deficit/hyperactivity disorder (ADHD), but they are also used to treat other conditions such as asthma, respiratory problems, obesity, and sleep disorders. Stimulants include Concerta, Dexedrine, and Ritalin.

What can I do to protect the young people in my life?

In addition to talking to children or grandchildren about the dangers of abusing prescription and OTC drugs, you can take the following steps to prevent these dangerous substances from winding up in the wrong hands:

1. Take a survey of all the medications in your home. What drugs do you have? Where are they kept? Would you know if any were missing?
2. Safeguard all drugs at home by keeping them locked out of reach when guests, baby sitters, or pet sitters are in the house. (The child-proof caps are not going to cut it!)
3. Ask friends and family to safeguard their prescription drugs, too.
4. Properly dispose of old or unused medicines.

How do I dispose of old and unused medications?

In its ongoing effort to fight prescription drug abuse in the United States, the U.S. Drug Enforcement Administration (DEA) has set aside Saturday, October 26, as National Prescription Drug Take-Back Day. Between 10 a.m. and 2 p.m., you can safely throw away your unused prescription drugs at designated collection sites around the country.

For more information on National Prescription Drug Take Back Day, and to find a drop-off site close to you, click here.

Caution: Stay away from Medicare Part D plans that have received sanctions from CMS

MH900349511This past week, I had to create a letter regarding a Medicare Part D plan that has been sanctioned by the Centers for Medicare & Medicaid Services (CMS) for conduct that “poses a serious threat to the health and safety of Medicare beneficiaries.”

Government sanctions, or penalties, are just one more reason it is critical for you to review your Part D options every year. If you are in a plan that has received sanctions from CMS, you definitely want to look for a plan that has a high star rating (3 ½ stars or better) to make sure you are going to receive the services you pay for and deserve.

SmartD Rx, a new Part D plan from the Smart Insurance Company, is one plan that is not currently accepting enrollments due to CMS sanction action (I guess the company is not so smart). Here is just part of the letter from CMS to Smart Insurance Company regarding its SmartD Rx plan:

The Centers for Medicare & Medicaid Services (CMS) hereby informs Smart Insurance Company (Smart) of its determination to immediately impose intermediate sanctions…

These intermediate sanctions will consist of the suspension of the enrollment of Medicare beneficiaries…and the suspension of all marketing activities to Medicare beneficiaries. CMS is imposing these intermediate sanctions immediately, effective April 23, 2013…because it has determined that Smart’s conduct poses a serious threat to the health and safety of Medicare beneficiaries.

In its short tenure as a Part D sponsor, Smart has experienced widespread failures in numerous important operational areas including:

• Smart inappropriately rejected drug claims at the point of sale (i.e., pharmacy counter);

• Smart failed to properly process coverage determinations (i.e., requests for drug coverage or payment and reimbursement);

• Smart denied enrollees the chance to appeal rejected claims and failed to ensure that denied coverage determinations were reviewed by an independent third party; and

• Smart failed to process enrollment and disenrollment requests, or failed to properly process enrollment transactions.

As a result of Smart’s noncompliance, its enrollees have experienced delays or denials in receiving prescription drug coverage and increased out-of-pocket costs.

CVS Caremark’s SilverScript is another Part D plan that received sanctions from CMS in 2013. In its letter to the SilverScript Insurance Company—a subsidiary of CVS Caremark – CMS wrote:

Since January 1, 2013, SSIC has experienced widespread data system failures that have directly led to extensive violations of the Part D program’s requirements regarding enrollment processing, call center operation, and claims processing. These failures have created disruptions in tens of thousands of Medicare beneficiaries’ access to prescription medications.

 From January 1 through January 14, 2013, CMS received 2,340 complaints about SSIC’s Part D operations. CMS has received complaints about SSIC at a rate four times greater than the rate of complaints received about all other Part D sponsors combined during the same period.

Other Medicare plan sponsors that have been sanctioned by CMS in the past include HealthNet,  Arcadian, and Universal American (all 2010), and Universal Health Care Insurance Company (2013). You can go to the Part C and Part D Enforcement Actions page on the CMS website for a complete list of plans that have received sanctions and other enforcement actions or had sanctions lifted.

How to get out of a bad Medicare plan

If you are enrolled in a plan that has been sanctioned, and you have personally been affected by your plan’s poor performance, you may be able to get out and switch plans outside of the Open Enrollment period. Your chance to switch is determined by CMS on a case-by-case basis, so you’ll need to call Medicare at 1 800 MEDICARE (1 800 633-4227), 24 hours a day, 7 days a week. TTY: 1 877 486-2048. Or go to this page at for more information.

How the DMEPOS Medicare Competitive Bidding Program could affect you

MB900366334If you are a Medicare beneficiary and have Original Medicare you may have received a notice from Medicare in May about the Durable Medical Equipment Competitive Bidding Program. This program was put in place to help lower the costs of durable medical equipment and supplies for people with Original Medicare. The program is expected to help Medicare beneficiaries save $17 billion between 2013 and 2022.

 In January 2011, Medicare began phasing in the Competitive Bidding Program in some parts of the country. The program requires providers and suppliers of certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) to submit bids for their products. Qualified suppliers with winning bids who meet strict quality and financial standards are then chosen as Medicare-approved contract suppliers.

Under this new program, if you have Original Medicare and live in a competitive bid area, you almost always have to use a Medicare contract supplier if you want Medicare to pay for certain DMEPOS products and services. According to Medicare guidelines, durable medical equipment (DME) is equipment that:

  • Serves a medical purpose;
  • Can be used in your home;
  • Can be used over and over again;
  • Is likely to last for 3 years or more; and
  • Is prescribed by your doctor or other health care professional.

Some examples of DME include walkers, wheelchairs, power scooters, diabetic testing supplies, and oxygen tanks.

The DME Competitive Bidding Program only affects those with Original Medicare, the traditional Medicare program directly administered by the federal government (Part A and Part B). It does not affect those who have a Medicare Advantage plan, also known as a Medicare private health plan. If you have a Medicare Advantage plan, you should contact your plan to see which suppliers are in the plan’s network of providers and will provide DME to you at the lowest cost.

The main purpose of the Competitive Bidding Program is to replace the prices Medicare currently pays for DMEPOS items with lower, more accurate and more current market prices. By using prices set through competition and ensuring suppliers are all licensed and accredited, the program will:

  • Reduce your out-of-pocket expenses
  •  Help Medicare and taxpayers save money
  • Ensure you have access to quality supplies and services from reliable suppliers
  • Help reduce Medicare fraud and abuse

Important News about Diabetic Testing Supplies

As of July 1, 2013, the Competitive Bidding Program was expanded to 91 regions of the United States. It was also expanded on a national level for mail-order providers of diabetes testing supplies. If you order your diabetes testing suppliers through the mail, you must now use a Medicare contract supplier if you want Medicare to cover your costs. Medicare will still provide coverage if you get your supplies from a drugstore or other retail facility, but you will pay less by using mail order.

For more information about how this program may affect you, check out the website. This site has a good article about the Medicare Competitive Bid Program as well as an online tool to search for a DMEPOS supplier.

If you use diabetes testing supplies, check out the article Diabetic Supplies and the Competitive Bidding Program or get a list of Competitive Bid Winners. The site also has articles about how the program will affect you if you use other equipment such as a power scooter or oxygen supplies.

To find out whether you are affected by the Competitive Bidding Program, you can also contact 800-MEDICARE or go online and visit

The Blind Leading the Blind: Anatomy of a Medicare Part D Monthly Premium

At least once a week one of my coworkers on our Medicare Part D team will come to me with what they think is a simple job. ‘I just need you to write a short apology letter. It should be simple,” Karen will tell me. “I have a simple project for you. All you have to do is edit this web page for Medicare Open Enrollment,” Tina will say. “We just need to ‘Medicarize’ this brochure, so it will be simple,” Chris will state.

Inevitably, I always respond, “Nothing is simple with Medicare Part D.” And then as what appeared to be an easy project becomes more complex with each new logistical problem that arises, I say, “I told you so.”

One of the most complicated “parts” of Part D – and thankfully, one that I have absolutely nothing to deal with – is what we call the annual Medicare bidding process. As our director of actuarial services notes, the process of bidding on Medicare prescription drug plans is a lot like putting together a giant puzzle. When the puzzle is completed, you end up with a monthly Part D premium of $32.07 or $41.29 or some other odd amount that seems completely random.

Unlike the commercial insurance market where providers set the premiums for a plan, Medicare Part D premiums are determined as part of a blind bidding process that begins in June of each year. Every Part D provider submits bids to the Centers for Medicare & Medicaid Services (CMS) without knowing what the competitors will offer. Then CMS sets premiums based on how the bids average out. Premiums may vary from what providers submitted depending on what their competitors bid and how they differ from expectations.

A few large competitors dominate the marketplace, so the ability to predict premiums, profitability and potential membership growth requires an educated guess as to how other Part D providers will bid. The guesswork can be quite complex and requires a detailed understanding of trends and potential growth strategies in the marketplace.

For example, is a large Part D provider going to try to maximize profits by bidding a higher number or are they looking to increase membership and so plan on submitting a lower bid to CMS? Data and historical trends are helpful, but it’s really more of an art than a science when it comes to making a good bid that has competitive premiums and features that Medicare beneficiaries want in a Part D plan.

During the next two months, CMS will thoroughly review each bid. In August, CMS will release the bid results, giving marketing departments and employees like me just barely enough time to create all the plan materials and marketing communications for Medicare Open Enrollment in mid-October.

Yes, you can switch your pharmacy at any time with Medicare Part D

Walgreens survey about Medicare Part D

This infographic from Walgreens explains some of the findings from a recent survey regarding beliefs about Medicare Part D.

Today I had an “ah ha!” moment at work.

For years I have been telling the over 2 million Medicare beneficiaries in my company’s Part D prescription drug plans that they can often save money by using a different pharmacy. Using a mail-order pharmacy almost always yields savings, as does switching to a preferred retail pharmacy that offers lower co-pays or moving to a pharmacy that simply charges less money overall for prescription medications.

And for years I have been wondering why so few Part D plan members are taking my advice and using a more cost-effective pharmacy. Why aren’t seniors taking advantage of these savings opportunities?, I have often asked my coworkers and friends.

This morning I came across the results of an April 2013 Walgreens survey that answered my question — or at least, provided one explanation.   According to the survey, almost 30% of the 1,000 beneficiaries surveyed did not know that they can switch pharmacies at any time during the year. These 300 Medicare enrollees falsely believed that they could only switch to a new pharmacy during Medicare’s annual Open Enrollment Period.  In other words, they thought that if they were using XYZ Pharmacy when they first enrolled in a plan, they’d have to stick with XYZ until Open Enrollment (October 15 to December 7 of each year).

Although many Medicare beneficiaries shun mail-order pharmacies, even though using mail order is one of the best ways to save, retail pharmacies in a preferred pharmacy network are a great alternative for some people. Using a preferred pharmacy — if the Part D plan offers a preferred pharmacy network and there is a preferred pharmacy close to home — can potentially save beneficiaries hundreds of dollars each year on prescription drug co-pays.

However, it looks as though few people are taking advantage of preferred pharmacies. In fact, only 21 percent of respondents switched to a pharmacy within their plan’s preferred network as a way to save. One-fourth (24 percent) said they were unaware of whether their plan offers a preferred pharmacy option.

The survey  “underscores the need to educate Part D beneficiaries about how they can save on prescription and other health care costs,” said Dan Luce, director of pharmacy affairs, Walgreens. Many more Medicare Part D plans are starting to offer preferred pharmacy networks, so I guess I have my work cut out for me.

Medicare No Longer Pays for Vitamin B-12 Injections — and it’s All Obama’s Fault

Medicare True or False
Is the headline of this post true or false?

If you are a person who believes everything you read on the Internet, then you may be inclined to say it’s true. If, on the other hand, you question everything that sounds too good to be true or simply too unbelievable, then you probably think it’s false—but you’re going to do more research to double-check.

A recent State Farm commercial features a man and a woman discussing mobile apps. During the conversation, the man asks the woman why she believes something he said, and she tells him it’s because she read it on the Internet. “They can’t put anything on the Internet that isn’t true,” she tells him. Right then, an unattractive man walks into view. The woman tells her friend that the boorish man said he was a French male model on the Internet.

The point is, there are a lot of lies out there on the World Wide Web. And many of them have to do with horrible changes to Medicare coverage under the Patient Protection and Affordable Care Act (ACA). Many of the lies are ludicrous and primarily designed to instill fear in people.

The other day, my mom sent me an e-mail that she had received from a former coworker. She told me she was concerned about some of the things the letter said about Medicare coverage under the ACA, aka, Obamacare. Here’s just one excerpt from the e-mail:

Today I went to the doctor for my monthly B-12 shot that I have been getting for a number of years. The nurse came and got me, got out the needle filled and ready to go and then looked at the computer and got very quiet and asked if I was prepared to pay for it. She said that Medicare had turned it down and went to talk to my doctor about it. Fifteen minutes later she came back and said she was sorry, but they had tried everything they could but Medicare is beginning to turn many things away for seniors because of the projected Obamacare coming in.

I did some quick research on and and found out that this letter was one of many that began circulating when Congress was considering a healthcare bill called America’s Affordable Health Choices of 2009 (H.R. 3200). This bill was never passed by Congress. However, the letters continue to circulate, even though most of the points made in these letters are completely irrelevant, outdated, and have nothing to do with Obama’s Affordable Care Act (H.R. 3590).

Yes, Medicare does pay for B-12 injections – if deemed reasonable and necessary
Under Section 1862 (a) (1) (A) of the Social Security Act, Medicare covers services that are deemed reasonable and necessary “for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” For example, vitamin B-12 injections are covered, but only for diagnoses such as pernicious anemia, gastrectomy, and dementias secondary to vitamin B-12 deficiency. In addition, the frequency and duration of the administration of the medication must be within accepted standards of medical practice, or there must be a valid explanation regarding the extenuating circumstances to justify the need for the additional injections.

You should also make sure your doctor’s office uses the correct codes when billing Medicare for B-12 injections. According to what I read on the American Academy of Professional Coders website, some Medicare Advantage Plans will not pay for the injection if the doctor also bills Medicare for an Evaluation and Management service. Other plans require a diagnosis code in addition to the codes for the administration and drug code. So if you get your coverage from a Medicare Advantage Plan or Medigap supplemental plan, you should ask what documentation the plan requires for coverage before getting your first injection.

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