The Union has received a Labor Notice regarding coding issues that impacted certain mail-order (Maintenance Choice/mail service) prescription drug claims across multiple medical plan options, under NIC, Mobility Purple, West CWA and IBEW, and Southwest.
These issues impacted mail-order prescriptions only; retail pharmacy copays were not affected. The notice outlines the identified issues and the corrective actions currently underway.
Summary of Identified Issues:
Issue #1 – Missing Coinsurance at Mail
Timeframe: January 1, 2025 – May 14, 2026
Description: Coinsurance was not applied to certain mail-order prescriptions.
Member Impact: Members paid $0 copays for generics and preferred brand drugs when coinsurance should have been applied.
Issue #2 – Mail Coinsurance Overcharge (20% vs. 10%)
Timeframe: January 1, 2025 – May 14, 2026
What happened: Mail coinsurance was set at 20% instead of 10% for generic & preferred brands.
Member impact: Members paid higher-than-expected coinsurance.
Issue #3 – Specialty Coinsurance (10% vs. 20%)
Timeframe: January 1, 2025 – December 31, 2025
What happened: Coinsurance was set at 10% vs 20%.
Member impact: Minimal, as most claims hit the $100 max, but some claims paid at a lower coinsurance
Impacted Participant Counts
NIC: 64 impacted members / 828 claims
Mobility Purple: 522 impacted members / 2,609 claims
West IBEW: Counts under 50 (not disclosed for confidentiality)
West CWA: 1,280 impacted members / 4,392 claims
Southwest: 3,087 impacted members / 10,694 claims
Counts fewer than 50 are not reported to maintain confidentiality and protect personal health information.
(*For clarification, a claim is each time a prescription is filled; for example, one person filling five prescriptions equals 5 claims, while 100 people filling two prescriptions each equals 200 claims.)
Corrective Actions
Caremark will reverse and reprocess all impacted claims. Members who were overcharged will receive refunds via mail. Members who were undercharged will not be billed, and those costs will be absorbed by Caremark. For additional questions, please advise your members to contact CVS Customer Care at 800-378-8851.
If you have any questions or need additional clarification to support member discussions, please let me know.
Jim Winsett
President, CWA Local 6210