RX Coverage Carrier on a MAPD Plan

Jun 27, 2016

  1. Iwillpay
    Offline

    Iwillpay Guru

    Posts:
    766
    Likes Received:
    20
    Would like to hear from the GURUS on the forum if some MAPD carriers farm out the RX part of a MAPD plan to a company like CVS caremark (SS).

    I was helping a customer sort out her medication and when we call Walgreens the pharmacist said a particular generic drug was not covered by CVS caremark. Thinking she made a mistake we gave her the MAPD member ID number again and her reply was that ID number was covered under CVS caremark.

    You learn something new each day.
     
    Iwillpay, Jun 27, 2016
    #1
  2. kgmom219
    Offline

    kgmom219 What's Next?

    Posts:
    5,418
    Likes Received:
    493
    State:
    Texas
    Most MAPD (and other carriers) do not do their own Prescription Benefit Management (PBM).

    The largest PBM is CVS Caremark. Which is the PBM for many carriers, but also has its own Part D plan, Silver Script. I know Wellcare uses them as a PBM, but I don't know who else does for Part D. I would assume Aetna, too.

    Then you have Express Scripts, which has Anthem (who refuses to use Prime), but they are trying to get out of the deal, in anticipation of the Cigna merger, who has a better deal with Catamaran.

    Tricare also uses Express Scripts

    Humana has its own internal PBM, which is part of the antitrust concern with the Aetna merger, who currently uses Caremark.

    UHC bought Pacificare to get their PBM (and Secure Horizons) and its now evolved into Optum RX. But most people don't realize that Optum is part of UHC and its treated as a completely separate company internally at UHC.

    The Blues Association uses Prime Theraputics. But not all Blues subscribe, for various reasons. (Prime was created with the massive amount of cash they got when the CVS Caremark merger went through.)

    So..there you go. No, most carriers don't do their own PBM. All the PBMs have contracts with the pharmacies and drug manufacturers. Thats what creates the formularies. Its why 1 drug will 5 different prices at 5 different pharmacies.

    There ya go...probably way more than you wanted to know.....
     
    kgmom219, Jun 27, 2016
    #2
  3. Iwillpay
    Offline

    Iwillpay Guru

    Posts:
    766
    Likes Received:
    20
    Well done much more than I expected.
    The client in this case have a Wellcare MAPD.
    Now I see why they say that CVS is the preferred pharmacy.
     
    Iwillpay, Jun 28, 2016
    #3
  4. AllyriaRedbird
    Offline

    AllyriaRedbird Expert

    Posts:
    71
    Likes Received:
    3
    So helpful! Thanks.

    I wondered why there were different affiliations and your post explains it.

    Helpful to explain to folks about why they should go to one pharmacy over another for a certain drug, etc.
     
Loading...