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 Last week, much to our relief, the Centers for Medicare & Medicaid Services (CMS) rescinded the rule.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.

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

  1. L. Witlin on said:

    I agree that Medicare – AND my mail-order pharmacy – dropped the ball on not letting people know about the January 1 change. But I thought it was an excellent change as it let me confirm the validity of the prescription, whether or not I still wanted it, and the accuracy. Then, when it was changed in March, again I received no notice from Medicare or my mail-order pharmacy – Express-Scripts/Medco. When I found out that they had just sent out a new prescription to me without my approval, I called and they said that they didn’t have to get my approval. First, they claimed to have called me – I show an external call to you this morning – which was a lie since the phone never rang, and they have the correct contact information. Eventually they decided that I was right about Medicare making the change effective January 1, 2014, but they said that it was changed. I filed a grievance and was told too bad, that’s the way it is, and that I couldn’t even request for my account that nothing be automatically sent out. They said that the new change was that if I used mail-order once in the previous 365 days, then any Rx would automatically be sent out, with or without my knowledge or permission. Theoretically, I could stop mail order – though I’m not really sure how with automatic refills – but the way it’s set up, mail order is much cheaper than retail, which is why I use it and why I am paying so much for the plan.

    Contrary to their belief, doctors and pharmacies do make errors – I’m a doctor, so I definitely know. In the past few months alone, I have had 4 Rx’s that were either ordered in a wrong dose or quantity or filled incorrectly. Medco acknowledges that, once a doctor orders a prescription for me and they mail it, I am required to pay for it or I can’t get future prescriptions. But I may not even have agreed to take the medication, may not know anything about it, it could be an error on the part of the doctor’s office including whether or not it’s even the correct drug or the right dose or even a drug that I’m taking, etc. I receive mail order drugs in a plain white plastic envelope, with no way of knowing what is inside until I open it. Once I have done so, as you say, I’ve bought it. If it’s pharmacy error, they say they will fix it, but if it’s doctor’s error, good luck having them reimburse me! I also noticed a script yesterday that a doctor’s office sent in to a retail pharmacy. The pharmacy holds the Rx and won’t let customers see it until it’s paid for, but, once that happens, if there’s a doctor’s error, they can’t take it back by law. In this particular case, my mother has been using the new Rx for about 3 weeks, and has been having significant symptoms. When I looked, it turned out that the doctor’s office had sent in an Rx for half the correct dose. Not pharmacy’s error, doctor won’t do anything, patient has to pay for 2 Rx’s and have both count towards initial coverage limit. They won’t even allow the doctor to order an additional quantity to make up for the wrong dose and ask the Part D company to pay for it. I’ve had other Rx’s that have been filled in the wrong quantity (mail order) because of doctor’s error, and I have had to pay double or run out.

    Anyway, do you know of any way to require mail order pharmacies to allow members to make individual requests about their own accounts, in terms of approval, etc.? Or, do you know of anyone that I can contact about the issue? Other than someone at the 800 number who has no authority to do anything but repeat the policy to me.

    • I’m sorry you went through so much trouble — CMS was primarily at fault here, as they did not give any advance notice to the pharmacies about either the new law that went into effect on January 1, or when they rescinded the law in March. Without advance notice, Medicare plans were unable to get letters out or make phone calls fast enough to handle the volume in such a short amount of time. CMS had to rescind the law because literally hundreds of thousands of prescriptions were being held up at mail order pharmacies because people didn’t know they had to give consent — so thousands of people were not getting their medications, which of course created a very dangerous situation. In theory, the law was a good idea, but as usual, CMS didn’t think through the logistics and give Med D plans and pharmacies enough time to plan for and implement the change. Perhaps they’ll try to implement the law again after putting more thought into how it should work.

      Are you enrolled in Express Scripts Medicare (PDP) or do you get your Part D coverage through an employer or a Medicare Advantage plan? Since it appears that you get automatic refills (I think Express Scripts calls this Worry-Free Fills), I am assuming you get your coverage either via an employer plan or a Medicare Advantage plan. Either way, you can go online (www.express-scripts.com) and manage all your prescriptions that way. You’ll need to register online, but it just takes a few minutes, and then you can see all your Rx orders, cancel new orders and refills, postpone them, etc (I also have Express Scripts, so I always go online if I need to manage a script). If you are in Worry-Free Fills, this is the best way to take control of your own medication refills.

      For new scripts, I know it’s easiest to have the doctor call in or fax your prescription directly to the pharmacy, but it may be worth it for you, from now on, to ask for the actual script for any new medications and submit it yourself by mail. That way you are in control of the script — you can make sure that the dosage is correct, and you’ll avoid getting medications that you didn’t order or didn’t want. Once this new script is in your files, you can go online any time to cancel or postpone future orders.

      It is law that the pharmacy cannot take any medication back once it’s been through the mail, but Express Scripts should refund you any time there is a problem with the order. If you continue to run into problems, when you call customer service, ask to escalate the issue and they’ll direct you to a special department that handles complaints. If you use Twitter, you may also want to send them a note — no company wants to see bad customer service posted online, so you’ll probably get faster attention.

      Good luck, and let me know how you make out.

  2. Hi…thanks for this – great piece! do you have a link to the statement from CMS rescinding the ruling on shipping consent? i can’t seem to find

    • I will see what I can find tomorrow when I’m back in the office — thank you for reaching out.

    • OK, here’s what I found out. When I posted this article, I didn’t have all the details, but I knew that my company was no longer requiring the consent. I did some research, and found out that CMS issued a “New Fill Consent Exception” that exempted any beneficiary who had an established relationship with a mail-order pharmacy. In other words, if you had already been using a mail-order pharmacy, you would not have to provide consent for your prescriptions (new or refills). However, if it’s your very first script with a mail-order pharmacy, you do have to provide consent for those new scripts until you have an established relationship with the pharmacy.

      I apologize the confusion. Unfortunately, my company has blocked me from posting to my website at work, so I have not been keeping up with it and did not post any upgrades to this story.

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