CDPHP® recognizes the critical role prescription drugs play in the health and safety of our members, which is why we have made strategic investments in the future of our pharmacy strategy. Our pharmacy benefit changes are providing more options and better service for our members, plus more transparency and savings for your patients.
NEW PHARMACY BENEFIT MANAGER
A key piece of our pharmacy strategy is changing our pharmacy benefit manager (PBM) to Capital Rx.
By partnering with Capital Rx, CDPHP aims to stem the tide of rising drug prices through greater transparency, as well as a new pricing model that more accurately and fairly sets the cost of drugs. We are proud to say that Capital Rx sets its prices with full transparency using actual unit drug costs based on the National Average Drug Acquisition Cost (NADAC), which is maintained by the Centers for Medicare and Medicaid Services (CMS).
Capital Rx is more agile than any other PBM on the market. It can modify formularies in days rather than weeks or months, allowing CDPHP to seamlessly update our list of covered drugs. With Capital Rx, as new, more affordable drugs come to market, CDPHP will be able to offer those products more quickly to your patients.
Our new PBM goes into effect January 1, 2023.
CVS REMOVED FROM MEDICAID PHARMACY NETWORK
CDPHP works hard to provide our members with high quality care at an affordable price. However, the recent rise in health care costs – driven in part by skyrocketing prescription drug prices – continues to pose significant financial challenges.
With this in mind, and in the best interest of our members, CDPHP made the difficult decision to remove CVS pharmacies (including those located within Target stores) from our Medicaid pharmacy network effective January 31, 2023. Simply put, CVS was unable to meet the pricing agreed to by all other independent, chain, and supermarket pharmacies.
This change applies to all CDPHP Medicaid and HARP members. This change does not apply to CDPHP commercial, Medicare, Child Health Plus, or Essential Plan members.
Under certain circumstances, members may continue filling medications at CVS because an override will be in place allowing them to fill and refill prescriptions at CVS pharmacies. These circumstances include an emergency, if the member is having trouble finding another pharmacy, or if the member is having trouble getting a refill moved to another pharmacy.
CDPHP is confident that consumers will continue to have access to timely and affordable medications. Through our partnership with Capital Rx, we will be adding even more independent, retail, and grocery store pharmacies to the CDPHP pharmacy network.
CDPHP is sending letters to affected members notifying them of the change. We appreciate your support as you help your patients transfer to an in-network pharmacy. If patients need help finding a new pharmacy, they can contact the CDPHP Member Services team toll free at the CDPHP phone number listed on their ID card, Monday through Friday from 8 a.m. to 6 p.m., TDD/TTY: 711.
This change does not apply to specialty medications. Medicaid members still have access to CVS Specialty.
COMMERCIAL, MEDICARE, ESSENTIAL PLAN, AND CHILD HEALTH PLUS PHARMACY NETWORK
Members with commercial, Medicare, Essential Plan, and Child Health Plus coverage will continue to have access to national pharmacy chains and supermarkets (including CVS, Walgreens, Walmart, Rite Aid, Price Chopper/Market 32, Hannaford, Kinney Drugs, Wegmans, etc.), as well as most other pharmacies they’ve had in the past. Although CVS is still in the CDPHP pharmacy network for these plans, we recommend members switching to a different pharmacy because CVS pharmacies typically have higher costs for prescription medications. This translates into higher out-of-pocket costs for your patients.
EXPANDED RX FOR LESS PROGRAM
Starting in 2023, The Rx for Less program is nearly doubling in size with the addition of several chain pharmacies, plus multiple independent pharmacies. The 2023 Rx for Less pharmacies are:
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ConnectRx
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Hannaford
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Market 32/Price Chopper
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ShopRite
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Walmart
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Kinney Drugs – Starting 1/1/23
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Rite Aid – Starting 1/1/23
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Walgreens – Starting 1/1/23
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Food Lion – Starting 1/1/23
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Giant Foods – Starting 1/1/23
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Stop & Shop – Starting 1/1/23
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Multiple independent pharmacies – Starting 1/1/23
CVS has opted to be removed from the Rx for Less program. Members are still able to fill prescriptions at CVS pharmacies after 12/31/22, but the Rx for Less discount will no longer apply. If members are currently filling an Rx for Less medication at CVS and would like to continue receiving a discount on prescriptions through the Rx for Less program, they can transfer applicable prescriptions to a different Rx for Less retail pharmacy.
Members can switch to a different Rx for Less pharmacy by downloading the CDPHP ConnectRx, On the Go app. They can also call the pharmacy that they would like to switch to and let them know they want to transfer their prescriptions there.
Rx for Less is available for commercial plans with prescription benefits (including self-funded plans) and Medicare advantage. Change goes into effect January 1, 2023.
PRESCRIPTION DELIVERY SERVICES
Members can skip the trip to the pharmacy and have prescriptions delivered right to their door – all at no extra cost!
Free home delivery from ConnectRx
Fast, free delivery is available to anyone in the broader Capital Region area with our ConnectRx pharmacies in Watervliet, Clifton Park, and Latham. Visit ConnectRx online to learn more.
Walmart Home Delivery is the new CDPHP mail-order pharmacy starting January 1, 2023
Our prescription mail-order service will now be administered by Walmart Home Delivery. This service is best for members who take medications to treat chronic conditions. Walmart Home Delivery is a prescription mail-order company, and your patients will not need to visit a retail Walmart location when using this service.
Current and new users of mail-order service will need to create a profile with Walmart Home Delivery before any prescriptions can be filled. On or after January 3, 2023, patients will need to call the pharmacy number on the back of their member ID card to setup an account. Once that's completed, prescribers may do one of the following:
E-PRESCRIBE to Walmart Pharmacy Mail Order 2625 or FAX prescriptions to 1-800-406-8976.
Your CDPHP member patients may still visit CVS retail locations to fill prescriptions, but they will not be able to have prescriptions delivered through CVS Caremark Mail Service Pharmacy.
The CDPHP mail-order service through Walmart Home Delivery is available for commercial plans with prescription benefits (including self-funded plans) and Medicare advantage. Change goes into effect January 1, 2023.
Synthroid and Alphagan update for mail order beginning in 2023
As you may know, CVS Caremark mail order uses brand-name Synthroid and Alphagan as their generic product to fill prescriptions. However, as CDPHP transitions to Walmart Home Delivery as its mail-order partner beginning January 1, 2023, we are letting providers know that Walmart uses generic versions of Synthroid and Alphagan.
For prescribers, this means if you do not state that brand-name drugs are necessary, patients will start receiving a generic version of these medications. We appreciate your support in helping educate your patients about this change.
FREQUENTLY ASKED QUESTIONS
Q: What do you know about Capital Rx?
A: With 150+ active clients covering more than one million lives, Capital Rx is one of the fastest growing health care companies in America and offers game-changing technology in both claims processing and benefit configuration.
Capital Rx is also known for superior customer service, including:
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Award-winning call center
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Award-winning customer service
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100 percent implementation satisfaction
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99.5 percent client retention
CDPHP believes Capital Rx will be a strategic business partner whose mission, vision, and values are very much aligned with CDPHP. We are also confident that – by partnering with Capital Rx – we will stem the tide of rising drug prices through greater price transparency, as well as a new pricing model that more accurately and fairly sets the cost of drugs.
Unlike other PBMs, which arbitrarily set rates based on secretive rebating and spread pricing, Capital Rx sets its prices with full transparency using actual unit drug costs based on the National Average Drug Acquisition Cost (NADAC), which is maintained by the Centers for Medicare and Medicare Services (CMS).
Q: Does Capital Rx fill prescriptions? Do members need to switch prescriptions to Capital Rx?
A: Capital Rx does not fill prescriptions because they are not a pharmacy. They will help CDPHP manage pharmacy benefits by processing and paying prescription drug claims, and more. It is not possible to switch prescriptions to Capital Rx.
Q: Are there any changes for specialty medications?
A: CVS Specialty will continue to be our national specialty pharmacy. Members will not have any changes to specialty prescriptions, costs, or the process to fill/receive specialty prescriptions.
Q: How do members view their pharmacy benefit coverage?
A: Members can view pharmacy benefit coverage by logging in to their CDPHP member account at member.cdphp.com. They can also download the ConnectRx, On the Go app to view their prescriptions all in one place. On the app they can also view cost-saving alternatives, change pharmacies, and receive updates about Rx benefit changes. Members can also call member services at the number on their ID card for assistance.
Q: Will members be receiving new CDPHP ID cards as a result of this change?
A: Yes. Members will receive a new ID card because there is new information on the card that the pharmacy needs to process prescriptions. It’s important that members bring the new ID card to their doctor’s office and the pharmacy starting January 1, 2023.
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Medicare members will also now only have one ID card, instead of two.
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Members of certain off-cycle groups will receive their standard member ID card in the fall season before the new year. This means that they will continue to have CVS Caremark through the end of the year and use their 2023 ID card until December 31, 2022. During that time, they will also receive a new 2023 ID card that lists Capital Rx as the pharmacy benefit manager, but that cannot be used until January 1, 2023.
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Members will be receiving their new ID cards between October and December.
Q: Will CDPHP be communicating the new PBM numbers (pharmacy “BIN”) to local pharmacies directly?
A: The new pharmacy identification number (“BIN”) will be communicated to pharmacies by Capital Rx via fax/email and by CDPHP representatives.
Q: Will the local member transition experience be different from a member who is in another state?
A: A member who is located out of state should not have a different transition experience than those who live in the state, but we cannot advise every pharmacy out of our area of this change. Members should present their new ID card each time they fill a prescription at a pharmacy.
Q: How is CDPHP letting members know about pharmacy changes?
A: CDPHP is communicating changes and clear action steps to all impacted members by sending letters, emails, text messages, and messages in the Connect Rx, On the Go app. Our member services team is also prepared to support members with any needed changes.
If a member doesn’t have to take any action, they will not receive a communication about the PBM change. Members who are impacted by a specific change will receive a communication. For example, a member who fills an Rx for Less drug at CVS will be directed to switch to a different pharmacy since CVS is no longer part of the Rx for Less program.
Q: Will prior authorizations and step therapy migrate over to Capital Rx?
A: Yes, this is an industry standard within PBM transitions.
Q: What reporting differences will we see related to standard monthly/quarterly/annual data?
A: We expect the reporting to stay the same. We will communicate any reporting changes that happen, if needed.