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Update on Reimbursement Situation

Wednesday, November 15, 2017   (0 Comments)
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Over the weekend CVS/Caremark updated its MAC list as they told PSSNY they would.   We have heard from members that the changes were negligible.
As a result, it is imperative that members continue to take the following steps to sustain awareness of this situation.
Contact the State Board of Pharmacy if your patients have been contacted by a PBM to transfer their script.

We have had alleged reports of patient steering.  Patients have been contacted to transfer their refills to a local chain pharmacy and/or to mail order. 

To report these instances:
You will find forms and instructions for filing a complaint.  Complaints filed by patients take priority.  The State Board of Pharmacy does not get involved in other aspects of this problem, so please narrow your complaints to patient steering concerns.
Call your PSAO.
  • Put the pressure on them to do something.
  • Members have reported that not all PSAOs are filing CVS/Caremark appeals even though you may have contracted for them to do so.  CHECK to make sure the appeals are being filed!
If you are in a Value-based Contract:
Contact your PPS and inform them of the patient impact this situation is creating.  Payments to hospitals in the value-based program DEPEND on patient adherence to their medication therapy.
  • Tell them to watch for an uptick in hospital readmissions and an increase in emergency room visits.
  • Ask them to report to you any changes they may be experiencing.
  • Ask them to report hospital impacts to the Office of Health Insurance Programs and to the managed care organization that is responsible for the patient. 
Continue to File Appeals
  • Submit underpaid claims via CVS Caremark's pharmacy portal.
  • Document everything!!
  • The more documentation you have, the more justification you have for complaints.    
  • Call Caremark's MAC Department: 1-847-559-3977.  We have heard that the voicemail is full.  You may not be able to get through.
  • Call with your specific claim grievances and document when you called, who you spoke to and what response you received. 
The first round of appeals forced Caremark to change the MAC list. They need to know the current list is inadequate. 

Contact NYS Medicaid Managed Care
  • Send pharmacy complaints to or call 800-342-3736 or 212-480-6400  
  • Patients can call: 1-800-206-8125
Call Your State Legislator
Please use the talking points below for guidance and follow up with a letter to document your concerns.

Follow-up Letter (downloadable Word document)
Call your federal representatives
What is PSSNY doing?
PSSNY continues to stay in contact with
  • The Governor's Office
  • The State Attorney General
  • The Medicaid Inspector General
  • General Counsel to the Department of Health
PSSNY is having conversations with legislators to determine what resources/assistance they can provide.