With the exit of Anthem Blue Cross in many regions of California, Blue Shield is working to make the transition for consumers who have enrolled in one of their health plans. They have released a bulletin about continuing care under a former health plan and transferring prescriptions to the new Blue Shield health plan.
Medicare Advantage with prescription drug coverage (MA-PD) contracts are rated on up to 44 unique quality and performance measures; MA-only contracts (without prescription drug coverage) are rated on up to 32 measures; and stand-alone PDP contracts are rated on up to 15 measures. Each year, CMS conducts a comprehensive review of the measures that make up the Star Ratings, considering the reliability of the measures, clinical recommendations, feedback received from stakeholders, and data issues.
Members who have used a Walgreens pharmacy at any time in the past 12 months will receive a letter about the change 60 days in advance of the end of the year if they have an individual and family plan. Group members will receive the letter 60 days in advance of their employer’s renewal date. The first letters mail late July to members of groups renewing October 1.
As part of our ongoing efforts to manage these drug costs, we are expanding our precertification program to include medical specialty edits. The expansion of our precertification program will allow clients who currently have our precertification program to benefit from these enhancements. There are two components to this expansion:
To make it easier than ever to find local level 1 pharmacies for your clients, refer to this Rx Choice Tiered Pharmacy list for California. A circle with either a 1 or a 2 next to each pharmacy indicates whether it’s a level 1 or a level 2.
CMS identified violations of Part D formulary and benefit administration requirements that resulted in UnitedHealth’s enrollees experiencing inappropriate denials of and/or delayed access to Part D prescription drugs at the point of sale. UnitedHealth’s violations include:
Sharp Health Plan has added an online drug price checker tool. The online tool is powered by PilotRx. Prices quoted are specific to the rates negotiated by MedImpact on Sharp Health Plan’s behalf. For more detailed medication information, Sharp Health Plan members should log in to Sharp Connect to receive the most accurate drug pricing based on their benefit plan.
The Rx Choice Tiered Network is comprised of more than 70,000 retail pharmacy locations in all. The network is anchored in Anthem markets, where offered, by CVS, along with Target pharmacies, now owned and operated by CVS. Members have the option to pick pharmacies at other retail chains and big box stores, as well as many independent drugstores.
Effective February 25, 2017, Sharp Health Plan is moving from Diplomat to CVS Specialty Pharmacy. According to Sharp, they found that CVS provides greater flexibility on how members can fulfill their specialty medication needs.
California Department of Insurance detectives, assisted by multiple law enforcement agencies, arrested Chris Bathum and Kirsten Wallace on multiple felony counts of grand theft, and identity theft for allegedly conspiring to defraud patients and insurers out of more than $176 million through an elaborate conspiracy. Simultaneously, search warrants were also executed at 15 locations throughout Los Angeles and Orange County.