State pharmacy switch sparks wave of drug denials, appeals and disruption
By Jenny Peterson
Mary Wise, a pharmacist and owner of Herold’s Pharmacy serving Charleston and West Ashley, says the Jan. 1 switch in the pharmacy benefit manager (PBM) contract for more than 550,000 state employees and retirees has caused major disruption for patients.
That includes denials of previously approved medications and even prescriptions that were long covered.
“We’re seeing a lot of denials even after prior authorizations,” Wise said.
She said patients are being pushed into appeals, switched to generics, or forced to pay out of pocket for brand-name drugs.
PBM Switch Disrupts Coverage
CVS Caremark replaced Express Scripts on Jan. 1 for the State Health Plan, a change authorized by PEBA, which manages insurance for South Carolina’s public workforce.
PEBA administers benefits for more than half a million members and regularly contracts with third-party administrators who manage formularies, or drug coverage lists.
“After careful evaluation of responsive vendors, Caremark was deemed most advantageous to PEBA and was awarded the contract,” PEBA wrote in its decision to switch.
Despite assurances that coverage would remain stable, Wise said patients are facing daily surprises and denials at her pharmacy.
“I have a friend whose daughter was on a medication for seizures and it was mandatory that she get the brand name. They had documentation she couldn’t take the generic and it was still denied,” Wise said.
Wise said this transition has been more complicated than expected compared to other PBM switches.
“I didn’t expect that there were going to be this many appeals and this many denials,” she said. “At the beginning of the year, it’s always overwhelming because that’s when you get a bulk of insurance changes, but it’s been more frustrating with this transition.”
One major issue has been coverage of GLP-1 weight loss drugs, including Wegovy, Mounjaro, and Zepbound, which were previously covered but are now being denied, even when previously authorized by a doctor, Wise said.
PEBA says its pharmacy benefit manager “uses a committee of independent physicians and pharmacists” to evaluate what drugs to cover that consider safety, effectiveness, cost and patient disruption.
During a federal oversight committee hearings in 2024 examining PBM practices, CVS Caremark CEO David Joyner said pharmacy benefit managers are important middlemen in negotiating drug prices for customers.
Caremark and PEBA didn’t reply to a comment for this article.
Impact on Patients and Pharmacies
Wise said changes to covered medications like this are not unusual in the PBM world, but the scale of disruption this year feels bigger than normal, especially for older patients who rely on stable coverage for multiple daily prescriptions and chronic conditions.
Wise added that the ripple effects are also showing up in pharmacy workloads, with staff spending hours each day on phone calls, doctors offices reprocessing claims, and tracking down prior authorizations.
She said the appeals process itself is adding stress for patients and providers, with doctors having to resubmit paperwork and pharmacies spending hours on phone calls to verify coverage.
For many retirees, especially those on fixed incomes, even a temporary denial can mean skipping doses or delaying treatment, which creates anxiety and sometimes leads to emergency room visits when conditions worsen unexpectedly.
While some patients worried Caremark would push them toward CVS pharmacies, Wise said that would be illegal, and that independent pharmacies like hers are still in network, though sometimes with higher copays.
Drug Denials and Appeals
Frustrated patients have taken to social media to share stories of coverage denials after years on the same medications, with posts drawing hundreds of comments from others in similar situations.
The issue has drawn attention from at least one political candidate, April Cromer, running for a statehouse seat in Anderson County. She said she has heard from constituents about delays, denials and sudden cost increases and took to social media to get more anecdotal stories about what’s really happening.
Wise said every day since the first of the year her pharmacy has heard a story about a denial, even with preauthorizations and being told by Caremark over the phone that their cases are still under review.
“There’s no clinical review happening in some cases — it’s just a denial coming through,” Wise said.
Calls for PBM Reform
She said she believes the current frustration will eventually push for greater reforms to PBM contracts at both state and federal levels.
There was no state oversight of PBM contracts just five years ago, Wise said.
“There’s a lot of politics involved,” she said, adding that change is likely, eventually. “It’s just taking time.”
