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Medicare Sanctions CVS/Caremark SilverScript Part D Plan

Medicare sanctions SilverScript PDP offered through CVS/Caremark

Medicare sanctions SilverScript PDP offered through CVS/Caremark

On January 15th, Medicare imposed an immediate sanction on SilverScripts Part D Prescription drug plans, available through CVS/Caremark, from marketing or selling any new drug plans because of massive failures to properly handle prescription drug claims of new members.

CMS is imposing these intermediate sanctions immediately, effective January 15, 2013 at 11:59 p.m. EST, pursuant to 42 C.F.R. § 423.756(c)(2), because it has determined that SSIC’s conduct poses a serious threat to the health and safety of Medicare beneficiaries. (emphasis added)

SilverScript Insurance Company is owned by CVS/Caremark. CVS/Caremark bought Health Net’s California Part D membership in 2012 and now has approximately 4 million members across the U.S.

Medicare states that right after the first of the year they began getting calls from SilverScript members complaining about prescription copayments not being honored at CVS/Caremark.

A significant number of the SSIC enrollee complaints describe instances where the member had to pay more out of pocket than was required under the terms of the benefit plan because SSIC systems could not correctly adjudicate the member’s claims in real time. For some beneficiaries, this meant paying a higher copay amount while others were charged the full cost of the drug. In many instances, beneficiaries could not afford the higher charge and left the pharmacy without their medication.

After almost daily contact between Medicare and SilverScript, the issues could not be resolved. Medicare reports that,

SSIC management explained that an update of SSIC’s Part D data systems performed during late 2012 had led to significant disruptions in its enrollment, LIS tracking, and claims processing operations. SSIC has confirmed that tens of thousands of SSIC enrollees were affected by these system errors.

Through January 14th, Medicare had received over 2,340 complaints about SilverScript Insurance Company which was four times the rate for all Part D sponsors combined. This led to Medicare to pull the plug on SilverScript from marketing their prescription drug insurance plans.

These intermediate sanctions will consist of the suspension of the enrollment of Medicare beneficiaries (42 C.F.R. § 423.750(a)(1)) and the suspension of all marketing activities to Medicare beneficiaries (42 C.F.R. § 423.750(a)(3)).

The net effect is that there can be no marketing or signage of the SilverScript Part D Plan and they may not enroll any new members. This is essentially like locking the front door to a business. While SilverScript members can continue to have their prescriptions filled at CVS/Caremark, no new enrollments can take place until Medicare is satisfied that the problems have been resolved.

SilverScript closed to new enrollment until they satisfy Medicare.

SilverScript closed to new enrollment until they satisfy Medicare.

Similar sanctions by Medicare have lasted the better part of a year for some insurance companies that ran afoul of Medicare guidelines. It takes a tremendous amount of work and preparation to become certified to sell Part D Prescription drug plans. When a company is prohibited from selling new plans it puts a serious kink in their business model to enroll new members throughout the year.

Medicare takes these violations seriously because they pay the plan upwards of $80 per month for each enrolled member and they have vetted the companies as being able handle the claims and customer service in a timely manner. It will be interesting to see how long SilverScript is on sanction and what it will do to their star rating once they are able to sell again.

SilverScript released from sanctions

On December 20, 2013, Centers for Medicare and Medicaid issued a letter releasing SilverScript Insurance Company from all intermediate sanctions. While SilverScript has addressed the poor quality customer service that triggered the sanctions, CMS still has concerns as they noted in their letter to SilverScript Insurance Company President Todd Meek –

CMS still considers SSIC to be a high-risk sponsor, and will continue to closely monitor and oversee SSIC’s operational activities. SSIC will be subject to targeted monitoring, including heightened surveillance and oversight. (full download of letter at end of post)

The games continue

Many people that have contacted me complain that they been enrolled without their knowledge into the SilverScript program and have tried repeatedly to disenroll. It is a cleaver game on the part of many large companies that continue to take the government subsidy payment every month while they continue to invoice for insurance that the consumer never uses. This would be a triple bonus for a company like SilverScript, they get to receive the government payment to subsidize the insurance, they never have to pay a claim because the member never uses the Part D Plan, and they get to deduct the “uncollected” debt of unpaid premium invoices off of their taxes.

2014 SilverScript enrollment

If you have been enrolled in the SilverScript Part D Plan without your consent and SilverScript re-enrolled  you in their PDP for 2014, and you don’t want to be, send me an email and I will put you in touch with others that are in the same boat. Individually your complaints to CMS may not have much weight, but as a group you might get their attention.

Download the Medicare sanction letter here

CMS SilverScript Sanction Release

190.94 KB 108 downloads

See also CMS sanctions SmartD Rx PDP

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  • One in the know!

    This sanction never “hurt” or “stopped” Silverscript. They were only sanctioned on individual enrollments. They have continued to ‘take over” employer sponsored retirement plans. They can’t even get their premium billings out since the first of the year for their individual enrollees. They have not made a good enough effort to quit taking over retirement plans and fix their problems. They don’t care. They are in it for the money. Here is advice to those going from commercial Rx plan to Med D plan – it is not a smooth transition. There are many meds out there that are not covered by Med D plan. Even if you check before you enroll, there is no guarantee that it will be covered the entire year as the formulary can change from month to month. Be prepared to talk to your physician about Prior Authorizations and Appeals. Know your plan!

    • http://Www.insuremekevin.com/ Kevin Knauss

      Good Advice. By far the most confusing and time consuming aspect of selecting a Part D plan is checking to make sure specific drugs are covered. It isn’t always clear from the Medicare website which drugs are covered even though you put in your prescription drug list.

  • Janis

    Silver Script told us today that their system is so screwed up that they cannot even generate a bill. They had phoned me one day at 6AM and told me they wanted to talk to me about my account. When I phoned them back at a reasonable hour they stated they did not know what the call was about. I lodged a complaint, then they closed it. Come to find out my account has been in arrears for several months now…Gee! I hope someone files a class action suit.

    • http://Www.insuremekevin.com/ Kevin Knauss

      Wow, I am shocked. Usually the Part D contractor jumps on the problems outlined by Medicare and fixes them in short order. It has been months since they were put on sanction and you are writing that they still are having problems.

      You will have to check your enrollment agreement to see if civil action is even allowed. Some membership agreements only allow for arbitration under certain conditions.

    • amg1558

      My mother, 71, is dealing with the same thing Silver Script. It is August 2013 and they are still having billing issues.

      • http://Www.insuremekevin.com/ Kevin Knauss

        If you can, make sure you file a grievance with Medicare to make sure they know of the ongoing problems. On the upside, Open Enrollment will be starting in October and she can find another plan.

    • Emerald Hope

      Janis, I’m told the exact same thing. It’s Dec 2013 and apparently they can’t send bills and I’m told to wait….. I was told the exact same thing last December, January and February. “The system is a mess and we can’t generate a bill”. Now they said payments are not due until the 15th of January so there is no problem. My policy says they are due on the 1st of the month. They also tell me I didn’t have a coupon book this last year. Of course I did. I pay bills on time… I know exactly how I paid the monthly charges. They tell me I got a monthly statement. NO…… I received 3 statements in the last year. That was it. There is a problem with this company… Administration and customer service is no help. Really people, how difficult is it to send out bills on time? If I don’t pay on time they’d have a fit. Is this anyway to run a company?

      • http://Www.insuremekevin.com/ Kevin Knauss

        It sounds like CMS needs to do more than just sanction this company. If these problems are persisting late into the year that is not a good sign. This only underscores the need for Medicare beneficiaries to compare and shop around for PDPs each year.

  • Jody

    Because I signed up for the SilverScript Part D plan in 2013 I have paid more than $2,00.00 in co-pay. That is more than I have ever paid before. Now I will contact the Medicare people to try to get some help. I am in Kansas City, MO. Now I am just so hurt and poor.

    • http://www.insuremekevin.com Kevin Knauss

      If you haven’t, you should contact Missouri CLAIM http://www.missouriclaim.org/ 1-800-390-3330 They should be able to give you some guidance, review your Part D Plan and copays and possibly help you file a grievance with Medicare.

  • Deb

    My mom just got a bill, stating she has owed a premium for part D since
    January 2013. But she has the rider that Medicare sent her for 2013
    that states she owes zero monthly premiums for part D, 2013 and she
    never had to pay one before she was put on Silverscript. Seems to me
    that they are trying to get money any way they can now to try and stay
    afloat.

    • http://Www.insuremekevin.com/ Kevin Knauss

      It sounds as if your mother has been participating in the Low Income Subsidy program through Social Security that picks up the premium for the Part D plan.

      This invoice could be a computer glitch as Silver Scripts works to bring their system up to speed and compliance. First call Silver Scripts to see why the designation has changed. If you can, call Social Security to make sure that her eligibility is still “OK”. They may direct you to your state’s Medicaid program.

      If you get the run around, let me know and I might be able to track down good contact numbers for the different programs.

  • CYNTHIALOULOU

    I was suppose to have SilverScript for Prescription coverage since Feb 2013. However, I have not been able to access my coverage since then. It is provided to me by my former employer and SilverScript said it’s Medicare’s fault that I have not been able to get my medication since Feb. I have spent countless hours with them & my former employer has too. They have had to send over files every month and speak with the eligbility dept? SilverScript has never sent me an ID card, Although I have about 8 from Caremark. They Cancel my coverage each month. I have had to beg & beg for my medications since Feb 2013. I have had to go without my medications in some instances or pay out of pocket for them because Silverscript has denied my coverage since Feb. I have felt like I am going to have a heart attack from all the stress and lack of medication that I am suppose to be taking. I am so sick of SilverScript/Caremark. This time when I went to get my Cymbalta for Depression/Panic & pain they wanted 198.00. I usually pay 56.00 which is expensive to me. When I called them the guy put me on hold & came back and said it went to 207.00 while I was on hold? This Company should not be allowed to provide prescription coverage when they will not provide you with coverage? They have no idea what they are even doing?

    • http://Www.insuremekevin.com/ Kevin Knauss

      Such egregious violations of their contract might trigger a special circumstance to allow your previous employer to switch Part D Plans they offer to their retirees.

      Please file a grievance with the Centers for Medicare and Medicaid. If you need the links and forms for filing a grievance, let me know and I will get them to you.

      • Glenn Forman

        Mr. Knauss, would you please send me the links and forms for filing a grievance against SilverScript? Thank you for your time & help!

  • Diane Evans

    Wow – I’ve had no problems with SilverScript. They pay what they should, I pay what I should, and they are the best value for my particular small # of drugs. I hope they get fixed and re-instated soon.

    • http://Www.insuremekevin.com/ Kevin Knauss

      I’m so thankful that you have had a positive experience with SilverScripts. I truly believe that the Medicare contractors really try to provide the best service for their member. Unfortunately, computer issues and the change of pharmacy benefit managers can get the best of any plan.

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  • Delfim

    I just spoke with two reps from SilverScript–we have lived in Portugal since April 2011, my husband is 80 and wanted to return to our country to die. All of a sudden we received an invoice for $353.50. Talking with the last rep he stated that the bill is now $38-.– (something) . When I mentioned my husband, the rep, would no longer talk with me because SilverScript does not have a power of attorney on file. Unfortunately, my telephone was dieing, so after asking the rep to have his supervisor telephone me back we got disconnected. At the beginning of the conversation (with each rep) I mentioned about knowing that they have been bought by CVS and the issues with SS and that SilverScript can no longer accept new members. I feel that SilverScript has made an error; because we do not need the policy in Portugal and they will not even talk with me to say what this amount is for.

  • Johnp

    A question: Reading about a host of problems, big big big problems with SilverScript, is this the same SilverScript Insurance Company that all NYSHIP members holding Empire Plan Medicare Rx prescription drug plan WILL be mandated to enroll with? Tell me, please, that is not so.

    • http://Www.insuremekevin.com/ Kevin Knauss

      I honestly can not tell you if this is the same company or not. Given that this Silver Script is still under sanctioned, the last time I looked, I can’t see how they would be able to enroll new members in NY when one of the sanctions is the prohibition of enrolling new members.

      • Johnp

        Thank you Kevin. I have received several letters from NYSHIP indicating that me and thousands of other NYS retirees will automatically be pushed into SilverScripts program on January 1, 2014. I would have to agree with you that it doesn’t seem possible given SilverScript’s sanctions. But then again Obama was re-elected and I didn’t hink that possible either. I would appreciate you checking on NYSHIP forced enrollment plans as to it’s accuracy. I haven’t contacted NYSHIP yet so possibly the letters I am receiving are a scam. Thanks for your reply.

        • http://Www.insuremekevin.com/ Kevin Knauss

          Well, you are right, it is the same Silver Script that is on sanction for individual Part D Plans and not employer based programs. The plan as outlined looks pretty competitive to what is available on the individual PDP market, plus it includes gap coverage.

          I suppose all you can do is notify NYSHIP. Maybe they don’t know about the Medicare sanctions. It also depends on who will be the pharmacy benefits manager. That was the problem they had last year was that they switch PBMs. It might be a separate entity from the individual PDP side.

          • Johnp

            Thank you again Kevin for your knowledgeable and informative reply. Truthfully, if NYSHIP did not know of Silver Scripts enormous problems, they must be living on another planet. Notwithstanding, I do thank you again for your responding to willingly to my questions and concerns. I do see problems down the road with the Silver Scripts, CVS and NYSHIP new relationship.

  • Bob P.

    For 2013 I have had Part D coverage under the SilverScript Choice plan. I have encountered no problems at all, and the coverage and price has been excellent. The price is going up a little next year, but it is still considerably better for me than any of the other options available through Medicare.gov.

    I know they haven’t resolved all their computer billing issues and aren’t accepting new enrollees (that’s why they say they don’t show up on Medicare.gov), so I am wondering if I am safe in sticking with them in 2014?

    • http://Www.insuremekevin.com/ Kevin Knauss

      If you have had good customer service with the plan, I am fairly certain it will continue. Most of the hiccups occurred with new members. In the words of our fearless leader, “If you like your plan, you can keep it.” I hope that doesn’t come back to bite me :)

      • Wayne Fogel

        I received a letter from my insurance company telling me they would not renew! I have been with them for 20+ years, it costs $1100.00 per month but I am very ill and they are excellent! NOT RELATED TO THIS INSURANCE COMPANY! 3 days later I got a letter from them saying they would renew because the president signed into law that they have to renew me! WOW! I feel special!
        I would die in a matter of days without my medications!
        The president’s words have teeth! I am proof!

        • http://Www.insuremekevin.com/ Kevin Knauss

          That’s good news Wayne. This is a real transition for everyone from health plans to government bureaucrats. At least one of the decisions rolled in your favor.

  • Claire

    Last week they denied a prescription that my fiance has been taking for years. They kept saying on the phone that everything was fine, and then when the pharmacist would run the prescription, it would say denied. I had to pay money on CHRISTMAS EVE, EVERY dime I had, for 6 days worth. He ran out on Sunday night and started withdrawals. Now I have been on the phone with them for 5 hours yesterday while at the pharmacy, and SIX hours today with no success. I don’t have 210$ to pay for this prescription, so he is still in withdrawal. Then they sent me on a wild goose chase and told me to go to a CVS that they had called after his regular pharmacy closed. They told me the address of the pharmacy, the name of the pharmacist, and the fact that he had 7 pills that would get my fiance feeling better untill Thursday when his regular prescription was due again. When I got there, that pharmacist knew NOTHING of me coming, did not know my fiance’s name, and refused to fill the prescription because ‘CVS has this Dr. on their ‘bad’ list. They lied to me every time I called and gave me a different excuse as to why it was being rejected. First they said, it must be a drug interaction. Then they said it was being investigated and it would take 72 hours. Then it wasn’t. Then they said it was they pharmacy’s fault, that they must have a glitch in their software. But other prescriptions went through. Then they said it was some code, that they had removed. Each time they told me to go back up to the pharmacist to have them run it because it would go through. Now it’s New Years Eve, and my fiance is so sick. He has had diarhea for 2 days now. He has diabetes but he won’t eat, and he won’t take his shots. So they tell me to take him to the ER. The ER will not treat him if he is in pain management though, so that is no use. This is CRUEL. I cannot believe the CIRCUS that I have been involved with the last 2 days. This is a nightmare for my poor suffering fiance, who just wants to be a little comfortable!!!!!

    • http://Www.insuremekevin.com/ Kevin Knauss

      No one ever takes responsibility. I wish these companies would just tell the truth instead of making excuses for their mistakes and lack of knowledge.

  • Della Richmond

    I have been denied Extra Help yet I cannot afford the drug co pays. I was told my amount would be about 38 dollars but they want permission to take up to 200 out on my debit at a time and if it is more they will let me know. I went to order Theophyline and the want to charge 98 so I un-ordereded it since I only have 30 in checking now!!! I am going to have to go without some of my more costly drugs now and I am on several for COPD so am very worried!

    • http://Www.insuremekevin.com/ Kevin Knauss

      It could be that your plan has deductible of approximately $320. After you meet the deductible, that’s when the brand name copays kick-in.

      If the Part D Plan sponsor won’t discuss and describe the elements of your current plan, then you can contact your local HICAP office for assistance – Health Insurance Counseling and Advocacy Program.

      Alternately, if you email me your plan with the description, I might be able to provide you with some more assistance.

  • Cathy

    I’m searching for a Medicare drug plan that uses CVS as a preferred pharmacy. I found Silverscript but after reading this article, I’m hesitant. I found a Cigna plan but the monthly premium is $115, more than I can afford. Can you recommend a plan that I can still use CVS as my pharmacy? Thanks.

  • roger

    Is there a direct relationship between the Anthem Blue Cross Medicare Supplement and Silver Script? We pay the bi-monthly premiums for my mother’s Anthem services but are not directly-billed for a monthly premium by Silver Script. When I have picked up prescriptions for my mother, I’ve been told they bill directly to the Anthem Plan D and that seems to satisfy the pharmacy; yet we get a monthly summary of coverage provided by Silver Script. Just trying to understand how this works.

    • http://Www.insuremekevin.com/ Kevin Knauss

      The Silver Script should be a wholely separate plan from the Supplement from Blue Cross. Depending on how old the Medicare Supplement is, there may have been a connection if the Blue Cross supplement dropped prescription coverage and Silver Script picked it.

      Otherwise, there should be no connection between the two, at least not in California.

  • Marvin

    I am a New York State Retiree who who was assigned to Silverscipt as my Part “D” provider under the New York State Health Insurance program. Last week I received mail from them threatening to drop me because I failed to notify them that I moved within the past year (about one mile from my previous address). The letter stated that they suspected that I was in jail or living outside the country, despite the fact that I continued to have my prescriptions filled by the same pharmacy in my area. They provided a form that I was to respond to updating my contact information. I immediately filled out the form and mailed it to them.

    They apparently didn’t waste any time…. When I attempted to fill a prescription today, the pharmacist told me that the records showed that my enrollment had “expired.”

    I’m not sure how to rectify this…..

    • http://Www.insuremekevin.com/ Kevin Knauss

      First, call Silver Scripts and discuss the situation. It sounds as if they are being over zealous in their attempts to squelch fraud, waste and abuse as directed by Medicare.

      Second, contact the retirement to see what your remedies are. It’s possible that your benefits travel with you regardless of whether you move in or out of state.

      Third, you need to file an appeal with SilverScripts either through their process or through Medicare. You would be appealing their decision to cancel your part D plan, even though they’ve been taking, and probably still receiving, the premiums on your behalf.

      Fourth, I would file a grievance against SilverScripts with Medicare. While you may have been in violation of reporting a change of address, it should not have jeopardized your prescription plan so quickly put you at risk of injury by not being able to access your medications.

  • Phil

    My wife keeps getting bills and late notices from SilverScript. We have never signed up or used there services. Can they send us to collections? We are trying to buy a house soon and need to keep our credit squeeky clean. How can I get them to bugger off without having to pay? We tried to cancel our “subscription but they said we need to wait till fall.

    Please Help if you have any advice!

    • http://Www.insuremekevin.com/ Kevin Knauss

      You have to get to the root of how you were enrolled in the plan. It’s possible that SilverScripts is the designated PDP for certain Medicare Advantage or retirement plans as a companion to the health insurance. If someone is in a low income plan such as Medicaid, then the state actually enrolls people who qualify for Medicare-Medicaid into a PDP plan they have contracted with.
      However, there should also be a low-income subsidy to offset the premiums of the PDP and potential some of the copayments. For this you have to go through Social Security.
      There is the possibility that you were enrolled but the billing isn’t accurate. You need to make sure that if you are properly enrolled in the SilverScripts, that the monthly premium matches what your medical plan says you should be paying for it.