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HCA warns hundreds of thousands of 2025 pharmacy claims will be re‑adjudicated after network programming error
Summary
HCA staff said a Navitus/MODA programming error used the wrong pharmacy network for UMP Classic Part D claims in 2025; staff told the board hundreds of thousands of claims will be re‑adjudicated, which could lead to member refunds or invoices and will depend on CMS direction.
HCA staff told the board that an adjudication error in 2025 requires a large-scale reprocessing of pharmacy claims for UMP Classic Medicare Part D enrollees.
Dave (agency staff) said the program’s pharmacy benefit manager, Navitus, via MODA’s administrative setup, incorrectly applied a network that included CVS for 2025 claims when the UMP Classic formulary should have been adjudicated on a network excluding CVS to realize preferential pricing. “This requires hundreds of thousands of claims from 2025 to be need to be re adjudicated,” Dave said. He warned the re‑adjudication could produce refund checks for members who overpaid and potentially invoices for members who underpaid, depending on CMS guidance.
Dave said HCA will coordinate communications in batches (quarterly cuts of claims) and will centralize intake for retiree inquiries. He also previewed a separate but related late‑enrollment penalty issue: CMS recalculated the national base premium, increasing the monthly late‑enrollment surcharge from $36.78 to $38.99. Dave said MODA will absorb costs for months where the increase was not loaded correctly but that members will be notified about the prospective increase.
Staff said a fuller presentation on the re‑adjudication process and member communication plans will come at the May board meeting.
