Part D Formulary and Benefit Administration

Issue: Errors in eligibility files leading to inappropriate rejection of formulary medications.

Impact: Enrollees experienced delayed access to medications, paid out-of-pocket costs, or never received medications.

Financial Penalty: CMP of $285,476

Transition Policy Administration

Issue: Incorrect transition timeframes due to errors in pharmacy benefit manager systems.

Impact: Enrollees faced inappropriate rejection of medications during transition periods.

Financial Penalty: CMP of $5,800

Prior Authorization and Exceptions Requests

Issue: Failure to effectuate approved prior authorizations, leading to denial of medications.

Impact: Enrollees were denied coverage despite having approved authorizations, resulting in delayed access or out-of-pocket expenses.

Financial Penalty: CMP of $14,152 

Coverage Determinations, Appeals, and Grievances

Issue: Failure to process coverage requests and appeals timely, improper classification of complaints.

Impact: Enrollees did not receive medications timely, paid more for drugs, or did not receive appeal rights.

Financial Penalty: CMP of $20,648

Program for All Inclusive Care for the Elderly (PACE) Program Compliance

Issue: Inadequate documentation and service provision, failure to meet participant needs.

Impact: Participants experienced gaps in care and unmet service needs.

Financial Penalty: Various PACE organizations faced penalties of $47,596 for non-compliance with program requirements