Pharmacy group comes down on health plans

NACDS has laundry list of actions health plans should take to help HIX beneficiaries

To provide for a smooth transition from coverage to care at the start of the 2015 plan year, the National Association of Chain Drug Stores (NACDS) urged the federal government to require that health plans provide nightly updates to patient eligibility files. This is just one of many actions the group wants health plans to take to help beneficiaries during the upcoming enrollment process

NACDS announced it wrote to the Centers for Medicare & Medicaid Services (CMS) to "recommend administrative changes to facilitate a smooth start for new exchange enrollees seeking prescription drug coverage in the 2015 plan year."

The group also recommends that exchange call centers remain open on all federal and state holidays during the December/January period. In addition, it called for implementation of functionality that would allow pharmacists to use one-time overrides in the month of January where they have difficulty adjudicating claims for new exchange enrollees, NACDS wrote to CMS Administrator Marilyn Tavenner.

"We remain concerned that patients may visit their pharmacy in January, shortly after enrolling in a plan, only to find that their coverage is not yet active," the group said in its letter. "Such scenarios are most likely to occur as a result of the failure of plans to provide nightly updates to the patient eligibility files."

CMS should make health plans pay for overridden claims once the claim is approved, NACDS recommended. This will provide patients with access to the drugs that they need while they work through coverage issues with their insurer, or work with their prescriber to find a substitute covered medication.

To learn more:
- see the statement (.pdf) 
- check out the letter (.pdf)

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