The Med Diva

An insider's guide to Medicare Part D and more

Archive for the tag “CVS Caremark”

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.


Don’t Settle for Lousy Customer Service in Your Medicare Plan.

Don't settle for a bad Medicare plan

Don’t get stuck in a jam if you don’t like your Medicare plan.

I recently came across a slew of complaints about the SilverScript Medicare Part D plan on the Complaints List website. (SilverScript is sponsored by the SilverScript Insurance Company, which is an affiliate of CVS Caremark.) The majority of complaints were about the drug plan’s customer service – or alleged lack thereof.

For example, Rita posted this complaint:

I’ve been treated rudely, after waiting on hold for an hour plus, sent to someone else after another 45 minutes, then that person said to hold and hung up on me. There should be a law about these customer service people treating the disabled elderly with more respect. Their day will come too. I feel as if they don’t care if we live or die and if we die without our meds they would be happy.

Now, I need to point out that last month the Centers for Medicare and Medicaid Services took action against SilverScript for issues related to claims processing (for example, some claims for new members were being rejected at pharmacies). Many of the complaints on the Complaints List website may be tied to this claims processing issue; however, it appears that the SilverScript customer service reps have not been properly trained on how to help people and treat them with respect.

No one should have to deal with horrible customer service. That’s why Medicare has established a 5-star special enrollment period.

Medicare uses information from member satisfaction surveys, plans, and health care providers to give overall performance star ratings to plans. As I’ve mentioned before, low star ratings typically mean lower quality and poor customer service.

Last year SilverScript earned only 3 stars from Medicare. This was the lowest star rating among the top 10 Medicare Part D plans in 2012. Based on all the complaints I’ve read, it won’t surprise me if the plan’s ratings drop even lower for 2013.

Here’s the good news for Rita and everyone else who has complaints about his or her Medicare plan: You may not have to settle for a plan with bad customer service all year long. That’s because you can switch to a 5-star Medicare Prescription Drug Plan or Medicare Advantage Plan if you are not happy with your current plan. The Special Enrollment Period for joining a 5-star plan runs from December 8 through November 30 every year.

Although very few plans have earned a 5-star rating from CMS this year, if you’re fortunate enough to find one that serves your area, you can disenroll from your current plan if you’re not satisfied and join a plan that has earned 5 stars.

Use the following resources to get plan ratings:
• The overall plan star ratings are available at the Medicare Plan Finder.
• You can call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
• You can download the Medicare fact sheet, which has additional information about star ratings.

Online tool helps people locate open pharmacies in storm-affected areas

During a disaster or emergency event, it is critical for people who take life-saving medications or drugs that control chronic conditions to have access to those medicines. I discovered this firsthand when my mom came to stay with me during Hurricane Sandy. She originally planned on staying only one night—she was overly optimistic about the power coming back on at her house—but when she heard the power was going to be off for at least a few more days, Mom began to panic a bit. She only brought a two-day supply of her medication, and was worried about having to skip a few days without it.

Luckily I know a thing or two about Medicare Part D, and was able to explain the situation to the CVS pharmacist in town. Even though my mom had just refilled her medication a few days earlier at her local CVS, the pharmacist was able to override Medicare’s  “Refill too soon” claim rejection because of the emergency situation. Within 10 minutes, Mom had her medication in hand.

We were very fortunate in that my home town did not sustain any damage, so I knew there would be no trouble getting her medication. But what about the less fortunate people in areas like Staten Island, Rockaway Beach, and Long Beach Island, where so many homes are in ruins? How would people know where to go to get the medication they needed?

I started to do some digging on the subject, and came across the Rx Response’s Pharmacy Status Reporting Tool.  The website provides real-time information about open pharmacies in storm-affected areas.  Granted, one needs Internet access via computer or smart phone to use the site, but it’s still a good tool for those employees and volunteers in emergency management and at emergency shelters who are trying to help people find the closest open pharmacy.

According to the site, Rx Response works with the National Council for Prescription Drug Programs (NCPDP) and pharmacy clearinghouses responsible for processing pharmacy payments. Once a request is made by a state emergency or public health official to begin pharmacy status reporting, Rx Response requests a list of all NCPDP pharmacies within an affected disaster area as well as a daily list of all pharmacies that are billing within the affected area. Once the data is processed, Rx Response displays a graphical, searchable map and downloadable Excel file of all known pharmacies, all open pharmacies, and any known affected/closed pharmacies.

The site is a bit clunky and not very user-friendly, but the concept is a good one that is much needed in this age of frequent storm surges. If anyone knows of a better site with this type of information, please let me know. With Sandy Part II expected to hit the northeast today and tomorrow, a lot of people may unfortunately be searching again for an open pharmacy.

Oops: Medicare Plan Mistakes Happen — More Often Than You’d Like to Think

Medicare errors happen

Medicare plans do make mistakes from time to time.

Last week I received a Google Alert about CVS Caremark Corp. and the Tufts Health Plan Medicare Preferred Plan. It seems that CVS mistakenly sent letters with information about the medical conditions of people in the Tufts Medicare plan to about 3,500 people enrolled in another plan. The letters also included information about some of the medications the Tufts Medicare members were taking.

According to The Boston Globe, CVS Caremark said a “programming error” was the cause of this information breach. The company said the information went to the wrong addresses in January and February, and included another member’s name, the name of a prescribed medication, and what the medication is used for. Fortunately, the letters did not include financial account numbers. CVS Caremark also said it doesn’t believe the information was used improperly.

“We are writing today to apologize for a system error”

For the past six years or so, I have been writing apology letters to members of Medco Medicare Prescription Plan for all kinds of system errors. Although I can only recall one time when the company sent information to the wrong addresses, I have written apology letters for many other kinds of mistakes. For example, we’ve had to apologize for inadvertently:

  • Failing to send a communication required by Medicare on time
  • Overcharging for  medications
  • Rejecting drug claims
  • Sending members the wrong plan materials

Medicare is a moving target

Thanks to the constant guideline changes and the enormous number of complex rules and regulations in the Medicare program, every Medicare plan is like a moving target; a constant work in progress. And now with all the changes under healthcare reform—such as the Coverage Gap Discount Program—that target is moving at the speed of light.

I can’t even tell you how many employees we have who are responsible for constantly updating our computers and databases to accommodate these changes—not because I literally can’t tell you, but because I simply don’t know. If I had to guess, I’d say a few hundred or more.

Medicare plan employees are sincerely sorry for these errors

So yes, system errors happen quite often, simply because it’s impossible for humans to keep up with all the changes coming at us from the Affordable Care Act and the Centers for Medicare & Medicaid Services. We try our hardest to prevent these mistakes from occurring, but sometimes a piece of computer code falls through the cracks. When that happens, we send every affected member an apology letter right away. It may not seem like much, but I want to ensure you that our apologies are sincere.

Lower Medicare Star Ratings Can Be a Reflection of Poor Customer Service

I have just unofficially confirmed that when you enroll in a Medicare plan with less than four or five stars, you may also forgo receiving star treatment from the plan’s customer service department. That’s why I’m going to step away from my planned series on proposed changes to Medicare for 2013 and share this story that demonstrates the significance of the Medicare star rating system.

No straight answers after spending one-half hour on the phone

This afternoon I received an email from one of my readers regarding a confusing letter she had received from SilverScript Insurance, the company that sponsors the CVS Caremark prescription drug plans.  Having just spent a half hour on the phone with SilverScript customer service—and still not satisfied with the answers she received (or should I say didn’t receive)—“Joanne” contacted me to ask if I could help her.

 “I don’t know about you, but people need blood pressure pills trying to talk to these customer service people,” she told me. “The first person I talked to had no idea what I was talking about so she told me to call this other number. Then that person also gave me another number to call.  When I called that number I got a fax machine. I just want a straight answer!”

 According to Joanne, she received a letter from SilverScript advising her that as a SilverScript plan member, she was entitled to the CVS ExtraCare Health Card, which provides a 20 percent discount on health-related products at CVS stores. The problem, however, is that Joanne is not a member of a SilverScript prescription drug plan.

Joanne said she called the customer service number listed on the letter to find out why she had received the card and whether there is any charge to use the card for non-members. Joanne told me she was transferred from one representative to another, but no one was able to answer her questions or even find her name in the ExtraCare database. The representatives all seemed in a hurry to end the call, she said.  “Maybe tomorrow if I’m in a better mood I’ll try calling back again.”

My first thought was that perhaps Joanne had accidentally enrolled in a CVS Caremark plan during Open Enrollment. It was also possible that a former employer had enrolled her in a CVS Caremark plan as part of a group benefit program for its retirees. Although Joanne would have received correspondence from the former employer advising her of this enrollment, there is always that slim chance that she put the notices aside or even threw them away, thinking it was junk mail.

I wrote back to Joanne and asked her if any of the above scenarios were possible. I explained why it was important for her to confirm that she had not been enrolled in a CVS Caremark plan – and to also confirm that she was still a member of her Part D plan of choice. (Because you can never be enrolled in more than one Part D plan at a time, had she enrolled in a CVS plan, she would have been automatically disenrolled from her current plan.)

 Customer Service did not take “ExtraCare”

My questions prompted an “Aha!” moment for Joanne. Turns out she was automatically enrolled in a CVS Caremark plan two years ago when the company that sponsored her former plan went out of business. Apparently the marketing firm for the ExtraCare card still had her name and address on record even though she was no longer a plan member. So it appears to me that the three or four customer service reps Joanne spoke to at SilverScript failed to take “ExtraCare” to ask pertinent questions in order to resolve what turned out to be a fairly simple matter. 

 SilverScript’s Medicare Part D plans (CVS Caremark Value and CVS Caremark Plus) may have received an overall rating of 3 stars from Medicare this year, but today I give their customer service department only 2 stars (and that’s only because I was finally transferred to Hope, who was able to answer one of Joanne’s questions: No, there is no charge to use the ExtraCare Health Card for non-members, but non-members do not get the 20 percent discount, so there is no benefit to using the card.) Thank you, Hope, for giving us at least one straight answer.


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