Caremark® Continues to Recover Payments for Unapproved Coupons

PAAS National® continues to see pharmacies face full recoupment on claims that are processed to coupons and copay cards in violation of Caremark’s® policy found in section 3.03.03 of the 2024 Pharmacy Provider Manual. Violations are considered [by Caremark®] to be an inappropriate waiver of patient pay amounts and could result in additional sanctions, including termination.

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As defined in the current Provider Manual:

“Pharmaceutical Manufacturer Coupon” means any item or mechanism, including but not limited to, paper coupons, copay cards, e-vouchers, mail-in rebates, and electronic coupon codes funded by a manufacturer, repackager, or supplier of pharmaceutical, chemical, or compounding products, that reduces the portion of the Patient Pay Amount that an Eligible Person is required to pay for a Covered Item.”

Manufacturer coupons may be accepted if:

  1. Pharmacy complies with all the terms and conditions specific to the coupon – including prohibitions on using for federally funded programs such as Medicare, Medicaid, and TRICARE
  2. The coupon is applied by your pharmacy location and not a hub
  3. The item is NOT a compound drug, 510(k) cleared medical device or Medical Food
  4. The item falls into one of the following categories:
    1. Approved as a brand (NDA) or generic (ANDA) drug and published in the FDA Orange Book
    2. Approved under a Biologics License Application (BLA) and published in the FDA Purple Book
    3. Over-the-Counter (OTC) item marketed under an official final OTC monograph

Log into the Caremark® Pharmacy Portal to find an electronic copy of the Provider Manual to become aware of the Pharmaceutical Manufacturer Programs and other associated programs that are excluded. Network pharmacies are mailed a paper copy of the Provider Manual every even year and small supplements in odd years.

PAAS Tips:

  • Pharmacies typically run afoul of Caremark with products sourced from secondary distributors identified as dietary supplements, medical foods or medical devices
  • These are typically products with large patient copays
  • Don’t assume that a product is “FDA approved” just because it has an NDC number
  • Use the following websites to determine FDA marketing status
  • FDA Orange Book: https://www.accessdata.fda.gov/scripts/cder/ob/index.cfm
  • FDA Purple Book: https://purplebooksearch.fda.gov/
  • DailyMed: https://dailymed.nlm.nih.gov/dailymed/index.cfm
  • If you are ever in doubt about a product, call PAAS so that we can help you identify whether it will be a potential problem

Kristen Sterzinger
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