Pharmacy Out of Network SEP??

[G.Gordon]

I got call last night from a client that received a letter from her pharmacy that Coventry MAPD has them as out of network. They do.

She said that she called the pharmacy and they offered to help her with a new plan selection. I told her AEP is over and since there are other pharmacies in network I don't think she can move, but would work on it Tuesday when I get back to work.

She said that the pharmacy told her since Coventry didn't notify the pharmacy until late in the AEP that she would have a SEP to change plans.

My guess is she might be right. Coventry plan selections were blocked out locally for the last few days of AEP.

My other guess is this will have to be a 800.M.gov change which knocks us out of the commissions.

Thanks Coventry.


I just ran a test for this client in her zip code.

Auburn pharmacy out of network.
Rockhurst out of network.
Miami county hospital pharmacy out of network.
Wal Mart, perferred pharmacy.

I'm going to have nightmares.

 

[TwoCents]

I got call last night from a client that received a letter from her pharmacy that Coventry MAPD has them as out of network. They do.

She said that she called the pharmacy and they offered to help her with a new plan selection. I told her AEP is over and since there are other pharmacies in network I don't think she can move, but would work on it Tuesday when I get back to work.

She said that the pharmacy told her since Coventry didn't notify the pharmacy until late in the AEP that she would have a SEP to change plans.

My guess is she might be right. Coventry plan selections were blocked out locally for the last few days of AEP.

My other guess is this will have to be a 800.M.gov change which knocks us out of the commissions.

Thanks Coventry.


I just ran a test for this client in her zip code.

Auburn pharmacy out of network.
Rockhurst out of network.
Miami county hospital pharmacy out of network.
Wal Mart, perferred pharmacy.

I'm going to have nightmares.

I wonder if the pharmacy is misinterpreting the special election for a signficant change in provider network. While the CMS guidelines don't specifically make the distinction, I would think most people would say it only providers to doctors and not pharmacies. The client would have to call 1800Medicare and I would think they'd decline her request to change plans.

 

[G.Gordon]

Finally got to talk to her at length.

Pharmacy again told her today that she can change plans Jan 1 - Feb 1.

So they are confusing parts of the MADP. I told her that she can change to a pdp, but not to another MAPD.

She balancing her options of changing pharmacies and buying outside of the insurance.

 

[midwestbroker]

I judge Medicare would take the stand that while a doctor change can be significant and warrant a SEP, changing pharmacies is far less a concern as filling a prescription from one pharmacy to the next should not have any effect on the outcome of the effectiveness of the medication.

Sure, your client may have to drive a bit further to have their meds filled, but that is not the concern of Medicare as they still have access to a pharmacy.

I would think if a client can make the case that they have to drive exceptionally far to have their meds filled (if they live in a rural market) they may get a SEP, but I would not bank on it.

 

[goillini52]

I judge Medicare would take the stand that while a doctor change can be significant and warrant a SEP, changing pharmacies is far less a concern as filling a prescription from one pharmacy to the next should not have any effect on the outcome of the effectiveness of the medication.

Sure, your client may have to drive a bit further to have their meds filled, but that is not the concern of Medicare as they still have access to a pharmacy.

I would think if a client can make the case that they have to drive exceptionally far to have their meds filled (if they live in a rural market) they may get a SEP, but I would not bank on it.

They could also use the mail order and possibly save some money.

 

[midwestbroker]

Good point. Medicare can claim they have access to the same medications, unless they need a antibiotic or something quicker than their usual meds. This would depend on the efficiency of the mail order pharmacy.

 

[G.Gordon]

She will not have a SEP. Unless she can show that the plan misrepresented the facts of pharmacy networking. She says that she read in one of the publications the plan sent that Auburn was not only in network, but preferred for 2015. She is yet to find that information again.

Her optons are stay on the plan or exit during MADP and enroll in a pdp.

Walmart is about the same distance as Auburn. Her medications are not very expensive.