Bookmark the new Broker Launchpad – guiding you to the right tool at the right time. View launchpad.

Close

Changes to the Pharmacy Benefits Administrative Services Schedule are coming

Large Group, Small Group, National | CO, CT, IN, KY, ME, MO, NH, NV, OH, VA, WI, CA, GA, NY-DOWNSTATE, NY-UPSTATE

We wanted to make you aware of a message that will be shared with your clients in the next few weeks. CarelonRx is making changes to the Pharmacy Benefits Administrative Services Schedule per the Administrative Services Agreement. Laws in several states are affecting pharmacy pricing and how your clients access pharmacy benefits.

These changes require the following updates to ensure continued compliance with applicable laws:

  • Claims from West Virginia, Arkansas, and Tennessee low-volume pharmacies will be excluded from financial pricing guarantees. This is due to mandatory requirements to reimburse pharmacies at National Average Drug Acquisition Cost (NADAC) and a dispense fee.
  • Retail cost share changes may apply if members are not allowed to have higher retail cost shares as compared to home delivery.
  • Exclusive specialty arrangements and mandatory mail requirements will not apply to impacted members filing claims in Florida, Oklahoma, Tennessee, and West Virginia. Members will have a retail pharmacy option.
  • Point of sale rebates will apply to claims from West Virginia and Arkansas. Rebate guarantees (if applicable) will not be affected.

CarelonRx will continue to honor the current pass-through arrangement in our agreement. Please advise us within three weeks of receiving this notice if you disagree with implementation of the contract changes discussed above. If we do not hear from you within that time, the changes outlined above will go into effect and we will provide updated contract documentation.