Dear independent pharmacy leader,

NCPA had a call with CMS this week and was able to find out the following information about upcoming changes in the Aetna / Coventry Part D plans:

It is our understanding that Aetna is planning to transition “back” to its previous network structure.  They are planning to do this in a “phased in” process that will consist of Phase I rolling out on March 31st—and then after assessing the overall success of the Phase I process-- they will move forward with a Phase II and III by May 1st. 

Phase I--- Plans that used or were originally listed as using the “Saver” network (the fewest PDPs and described in Aetna materials as “a smaller network with no preferred cost sharing”)—will now operate with Aetna’s “Standard” network (described in Aetna materials as “a broad network with no preferred cost sharing”).  We were told that Aetna has begun the process of outreach to beneficiaries and pharmacies to clarify for them what pharmacies they can utilize and what networks pharmacies are actually in.  Aetna and CMS estimate that there are approximately 1500 beneficiaries that are still filling claims at “out of network” pharmacies that will not be included in the “Standard” open network (i.e. contains no preferred cost sharing).    As of March 31, when any of these outstanding 1500 beneficiaries present prescriptions at an “out of network” pharmacy—the pharmacy will receive an NCPDP Reject 40 message.  This will also trigger Aetna outreach to the beneficiary within 24 hours letting them know that they have the option of choosing another in network pharmacy or contacting 1-800-MEDICARE to take advantage of the Special Enrollment Period (SEP) that allows them to choose another plan altogether.  This will also trigger outreach by Aetna to the submitting pharmacy to make sure that they have received standard terms and conditions (that they then may or may not accept).   CMS said there would also be a process in place for emergency fills in these situations.  CMS further indicated that the 2015 “re-contracting” efforts by Aetna has increased the number of pharmacies in the “Standard” network from 40k to 55k.  CMS also said that Aetna should be reaching out to pharmacies with updated “crosswalk” information that will further clarify this process.

 As we get further information on this process we will communicate it to you.