CMS Fines Aetna $1 Million For Faulty Pharmacy Identification

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By James Swann

April 7 — The Centers for Medicare & Medicaid Services imposed a $1 million civil money penalty on Aetna Inc. for falsely identifying in-network pharmacies to beneficiaries enrolling in Medicare Advantage and Medicare Part D drug plans for 2015.

Aetna will have until June 2 to request a hearing before the Department of Health and Human Services Departmental Appeals Board to appeal the CMP.

If it doesn't request a hearing, the $1 million payment is due June 3.

According to the CMS, 6,887 non-network retail pharmacies were listed as network pharmacies on Aetna's website, and customer service representatives also provided the false information to beneficiaries.

“After January 1, 2015, many Aetna enrollees presented with a prescription at their usual pharmacy only to discover that the pharmacy was not in their plan’s network,” the April 2 CMP notice from the CMS said.

As a result, many beneficiaries were either forced to pay cash for their prescriptions or left the pharmacy without them, the CMS said.

‘Avoidable Glitches.'

In an April 7 statement, John Norton, a spokesman with the National Community Pharmacists Association (NCPA), said seniors, caregivers and pharmacists were affected by “avoidable glitches.”

“As CMS noted in its letter, beneficiary complaints about these plans were five times greater than that of all other plan sponsors during the same time period and 73 percent of the complaints centered on misleading marketing about in-network pharmacy coverage,” Norton said.

The falsely identified pharmacies were initially uncovered by the NCPA, which began hearing about the issue from member pharmacies in January.

A representative from Aetna didn't immediately respond to an April 7 request for comment on the CMP.

Special Enrollment

Beneficiaries affected by the misidentified pharmacies were given a special enrollment period to disenroll from their Aetna plan and enroll in an alternative Medicare Part D plan, the notice said.

“This issue of non-compliance directly adversely impacted thousands of beneficiaries and had the substantial likelihood of impacting all Medicare beneficiaries enrolled in Aetna plans with incorrect pharmacy listings,” the CMS said.

In addition to imposing the CMP, the CMS notice said Aetna accounted for 33 percent (3,767) of all complaints received regarding Medicare Advantage drug plan and Medicare Part D issues.

Of the complaints against Aetna, 73 percent alleged that beneficiaries were given the wrong information about network pharmacies within Aetna plans.

To contact the reporter on this story: James Swann in Washington at jswann1@bna.com

To contact the editor responsible for this story: Kendra Casey Plank at kcasey@bna.com