This article states that CVS/Caremark, last year processed ONE-THIRD of all prescriptions. “processed” is a VERY VAGUE TERM, the PBM can reject a claim for various reasons, prior authorization required, days supply limits, they can and do determine how much the pharmacy is going to be paid and many pay the pharmacy – especially independents – less than the cost the pharmacy has to pay to the drug wholesaler for the medication. There is only about 5 PBM’s that control some 80%-90% of the entire out pt medication market.  The claim of 6.9 billion claims seem to be a “bit higher” than the number of prescriptions that are routinely claimed to be filled by pharmacies… That number is typically stated in the low 4 billion number. So is Caremark counting all claim rejections as “claims processed”. I would suspect that Caremark gets some $$ every time they handle a claim, even if it involves a rejection. That number would suggest that Caremark is REJECTING about ONE-THIRD of all claims filed.

System Issue At CVS Caremark Leaves Patients Stranded Without Medications

https://finance.yahoo.com/news/system-issue-cvs-caremark-leaves-140608072.html

Starting Monday morning, patients covered by CVS’s Caremark business experienced a halt in prescription processing, leaving some without their medications.

CVS Health Corp’s (NYSE: CVS) unit, Caremark, noted an “unexpected system slowdown” in a letter dispatched to pharmacists on Monday.

This issue affected all types of businesses managed by CVS Caremark, which funds prescriptions at thousands of drugstores, including those beyond the company’s outlets.

On Tuesday, a CVS Health spokesperson mentioned that a system issue impacted Caremark’s prescription billing and e-prescriptions. While the system is now operational, there might be temporary delays due to a backlog of prescriptions, Wall Street Journal reported. The cause of the issue was not disclosed.

According to the Drug Channels Institute, CVS Caremark, which processed 2.3 billion claims in the previous year, represents about a third of the market.

Carter High, co-owner of Best Value Pharmacies, reported prescription processing issues via CVS Caremark’s system starting Monday morning at his stores in the Fort Worth area.

High faced difficulties checking customers’ coverage, and he couldn’t determine whether the prescription would be paid for or how much the customer should be charged out-of-pocket.

Consequently, some customers were asked to return the following day unless they were willing to pay the full cost of the prescription up front.

The outage persisted throughout Monday, but prescriptions were being processed again by Tuesday morning, albeit with some delays.

Filed under: General Problems