Insurance Back Tracking with old PBM

[rxboy1996]

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Has anyone ever seen this? Our state's state employees PBM switched from PAID (medcost) to APM (CVS/Caremark) on Jan. 1. So I was processing a guy's rx for Temazepam last week with the new CVS/Caremark ins. It rejected with refill too soon till like end of March which I thought I was weird so we called. They said they would only pay for 45 capsules in a 75 day period and that the last time they got it was 12/23, however, when they got it on 12/23 it was through Medcost not Caremark. They said they were given all of their rx from the previous year from the other PBM. How is that fair? Their plans were different last year allowing to get the 30 capsules in 30 days.

Anyways, just a Prior auth no big deal. Just wondered if anyone has else has encountered this. It seems to be a trend with sleeping meds here.

 

[zelman]

Has anyone ever seen this? Our state's state employees PBM switched from PAID (medcost) to APM (CVS/Caremark) on Jan. 1. So I was processing a guy's rx for Temazepam last week with the new CVS/Caremark ins. It rejected with refill too soon till like end of March which I thought I was weird so we called. They said they would only pay for 45 capsules in a 75 day period and that the last time they got it was 12/23, however, when they got it on 12/23 it was through Medcost not Caremark. They said they were given all of their rx from the previous year from the other PBM. How is that fair? Their plans were different last year allowing to get the 30 capsules in 30 days.

Anyways, just a Prior auth no big deal. Just wondered if anyone has else has encountered this. It seems to be a trend with sleeping meds here.

I've seen those early refill issues when PBMs change. I guess they can argue that "your policy allows #30 every 25 days", not "your policy allows #30 every 25 days that we paid for".