Caremark Strictly Enforces Coupon Policy

Caremark Strictly Enforces Coupon Policy

CVS Caremark first updated their policy on the use of manufacturer coupons in May of 2017 and again in September of 2018. Pharmacies continue to suffer full recoupment of claims that were processed to coupons and copay cards in violation of Caremark’s policy. Caremark considers violations to be inappropriate waivers of patient pay amounts, and could result in additional sanctions, including termination.

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.

Caremark prohibits the use of any coupon for:

  1. Compounds;
  2. Federal health benefit programs, including Medicare, Medicaid, and TRICARE;
  3. Dietary supplements, devices, and any drug NOT approved by the FDA under a New Drug Application (NDA), Abbreviated NDA (ANDA), Biologic License Application (BLA), OTC Monograph, or otherwise Generally Recognized as Safe and Effective (GRASE);
  4. Certain programs identified by Caremark as being suspect include: Affordable Medication Solutions, RetainRx and Phoenix PBM.

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PAAS Tips:

  • Avoid using any type of coupon, rebate, or discount for unapproved drugs, dietary supplements, or medical devices
    • Vitamins and dietary supplements
    • Topical creams, emollients, lotions, and ointments that do not contain approved drug products
    • Saliva substitutes
  • Caremark’s definition includes programs that are provided by wholesalers and repackagers, not just manufacturers
  • Never use a program that is directly or indirectly funded by the pharmacy. These programs are schemes used to mask illegal waiver of copays and are considered fraudulent
  • Be cautious with any claim that has a copay greater than $100. High copays are intended to discourage patients from using non-formulary or non-preferred products and plans may require proof of copay collection and/or secondary processing information.
  • Be cautious with products that are not stocked by primary wholesalers; they are often unapproved products
  • Having an NDC does not indicate FDA approval. Check your pharmacy or wholesaler database for the FDA Marketing Category, NDA, ANDA, or BLA number. See NDC Number Does NOT Mean “FDA Approved” from September 2018 issue for more details.

Note: First DataBank (FDB) recently updated their database to list dietary supplements differently than approved drug products.