CMS Directs Drug Plans to Expedite Coverage Decisions - 03/07/06

Article from California Physician Online

To ensure that Medicare patients have uninterrupted access to medically necessary prescription drugs, the Centers for Medicare & Medicaid Services (CMS) has directed all Part D prescription drug plans to expedite coverage decisions for Medicare beneficiaries. The plans must make and communicate coverage decisions within 24 hours for an “expedited” request and 72 hours for a standard request.

Physicians can request an expedited decision if the patient’s health will be seriously jeopardized by waiting 72 hours for a standard decision.

CMS also directed all plans during this transition period to provide patients on stabilized drug regimens with at least a 30-day supply of their current medications, even if their particular drug is not on their plan’s formulary. The Bush administration has also asked drug plans to provide beneficiaries with an additional 60-day supply in emergency cases.
Full Story...

OHIO JURY FINDS MEDCO DEFRAUDED RETIRED TEACHERS; NCPA APPLAUD VERDICT - 03/07/06

Article from the National Community Pharmacists Association Online

The National Community Pharmacists Association (NCPA) applauded the verdict of an Ohio jury, when it decided that the giant pharmacy benefit manager (PBM) Medco Health Solutions Inc. should pay $7.8 million to the State Teachers Retirement System of Ohio (STRS Ohio) for breaching its fiduciary duty and for fraud.

The STRS Ohio board sued Medco in 2003 in the Court of Common Pleas in Hamilton County, Ohio, alleging that the company overcharged the retirement plan on generic drugs and inappropriately kept manufacturer rebates for itself instead of passing them on to the plan. According to the Attorney General of Ohio, this is the first time that a U.S. jury has recognized that a company managing pharmacy benefits has a legal duty to act in the best interest of retirees and pensioners. Full Story...

Medco could soon find out that cheap cures don't always last - 03/07/06

Until recently, the giant pharmacy benefit manager had expected to pay $42.5 million to settle a major class-action lawsuit. But an appeals court ruling will force a federal judge who presided over the case to re-examine the deal, raising the prospect that the settlement could collapse.

Medco has been accused of improperly favoring expensive drugs, especially those sold by former parent Merck (MRK:NYSE) , and then pocketing manufacturer rebates that should have gone to its clients instead. The $42.5 million settlement was negotiated three years ago, with Medco admitting no wrongdoing. Medco says it settled only to put the legal expense and burden involved behind it.

But the settlement hasn't ended the controversy over the case. The appeals court has challenged the legitimacy of some plaintiffs who settled on behalf of some 815,000 health plans in the suit. Four of the plaintiffs are simply individuals, the court points out, who have not shown that they were personally injured by Medco's alleged misconduct. And a fifth, it notes, is a health plan that has so far failed to prove that it ever had a contract with the big PBM.

The sixth plaintiff, a trustee for the Blumenthal Print Works represented by attorney Linda Cahn, has from the beginning rejected the settlement as inadequate. Meanwhile, 200 other Medco clients have declined to participate in the deal and left the door open for their own lawsuits instead. Full Story...

For more information regarding PBM litigation please visit the PBM Watch Newsroom
For more information regarding HMO litigation please visit the HMO Crisis Newsroom

No representation is made that the quality of legal services to be performed is greater than the quality of legal services provided by other lawyers.