For independent pharmacies across the country, 2024 has been a financially turbulent year. From the “DIR apocalypse” of Q1 to changes in reimbursements from many payors in the first months of the year, managing your pharmacy’s financials may be more difficult than ever.
However, while the road to progress is a slow one, the path yields game-changing results. Pharmacies in North Carolina are expecting an unexpected — but welcome — change in reimbursement rates.
CVS Caremark and GoodRx have ended their partnership, resulting in a notable increase in reimbursement to the pharmacy along with lower patient copays.
Read on to learn more about what this means for your pharmacy and how RedSail Technologies pharmacies can ensure they don’t lose on any profit.
Many pharmacies have experienced unexpected claims stemming from the Caremark® Cost Saver program aimed at lowering out of pocket drug costs for their patients.
In a press release from last October, North Carolina State Treasurer Dale R. Folwell, CPA, announced that some State Health Plan members will enjoy lower prescription drug costs at the pharmacy starting on January 1. The plan partnered with CVS Caremark and GoodRx to provide a free mobile app to help patients find the lowest prescription prices.
Since then, many pharmacies have noticed claim messages that indicate a coupon had been applied. These pharmacies may commonly find “CLAIM PAID NON-CMK DISCOUNT CONTRACT” text in the extended message of the claim and EDI Response Plan ID (FO) - GDX and Network Reimbursement ID (2F) - 003585GDRX as described in slide 28 of this recent presentation from American Pharmacies. Claims with this information often include a negative remittance of $6 or more.
Now, a light shines at the end of the tunnel.
At the time of writing, neither CVS Caremark nor GoodRx have made a formal press release on the end of this relationship in North Carolina. However, many North Carolina pharmacies are now reporting that the Cost Saver program is no longer being applied to claims, resulting in a notable increase in reimbursement to the pharmacy along with lower patient copays.
Having fought the good fight against PBMs in North Carolina for years, Table Rock Pharmacy’s Jessi Stout expresses relief and amazement over the recent events.
“I — and other pharmacy owners across the state —haven’t seen any negative remit claims since July 16,” Jessi says. “Caremark is no longer charging us a fee to fill prescriptions, reimbursement has gone up, and in some cases, patient copays have even gone down! It shows you that persistence pays off and standing up for what is right can make a difference!”
You can view part of Jessi’s appeal to the state health plan Board of Trustees here.
Current claim data is showing drastic claim improvements for pharmacies and patients alike, but only if the pharmacy removes its negative reimbursement mitigation techniques.
Since January 1, many North Carolina pharmacies have found the following steps alleviate the negative reimbursement by effectively opting out of the Cost Saver program on the claim:
Vigilant pharmacies that have been able to mitigate the negative reimbursements prior to July 16 are now finding that refills that carry the mitigation technique above are leaving money on the table.
PioneerRx’s Director of Education Will Tuft stated that “in most pharmacy software systems, the pricing added to the previous claim will be carried to the latest fill, so a pharmacy that is using the manual price entered prior to July 16 will not see an increase in their reimbursement on the next fill unless they submit their normal price.”
While there’s no action required by PioneerRx pharmacies to see the changes in their claim reimbursement, they must bill the plan with the default pricing elements in place.
Will continues:
“Pharmacies utilizing PioneerRx have been able to utilize the Manually Priced Third Party System Rx Edit to provide workflow alerts for claims that have been manually priced. This can easily identify claims at risk of missing their reimbursement potential.”
PioneerRx users can watch this video from PioneerRx University for more specifics on catching opportunities to increase reimbursement.
Multiple pharmacies have shared resoundingly positive feedback, highlighting the importance of unrelenting advocacy in the industry:
“Overall, I'm seeing an increase in patient cost, which in turn is an increase in our GP. The instructions on making the category and care plan were easy to follow and stopped data entry from proceeding.”
Melinda C. Childress, PharmD, MBA - Banner Drug
Matt Osterhaus, CPESN Iowa President and Osterhaus Pharmacy Owner, recounts similar success with that state’s pharmacies, highlighting the power of pharmacy advocacy:
“CPESN Iowa engaged with two commercial plans (including the largest commercial insurer in the state) to remove CPESN pharmacies from GoodRx’s “cost-inflator program.” It was our persistence and the power of our aligned network that secured a win for our patients and community pharmacy.”
2024 has been a challenging year for independent pharmacies across the country, but recent developments in North Carolina offer a glimmer of hope. Pharmacies in North Carolina need to take advantage of this opportunity. Doing so can give your pharmacy some much-needed financial relief at a time when PBM reform is still ongoing.
As of now, states like North Carolina and Iowa are enjoying the impact of pharmacy advocacy. Make your voice heard by reaching out to your policy makers and elected officials and join groups like CPESN and NCPA to further amplify that voice,
By staying informed and adapting to these changes, your pharmacy can maximize its profits and continue providing essential services to your community.
