PBM system errors result in member notification and reimbursement

Email This Page

Group Health moved to a new Pharmacy Benefit Manager (PBM), OptumRx, on Jan. 1, 2016. Despite months of planning, work, and programming to prepare for the transition, it became clear there were issues once members started using their pharmacy benefits within this system.

The problems included incorrect prescription drug information being programmed into the PBM system—an issue that we immediately addressed. After the mistakes were corrected, there was considerable work done to understand the impact that the programming errors had on our members.

We found that some members had been overcharged and had paid incorrect cost shares. Beginning June 13, 2016, all affected members will receive a letter from us, which will inform them of the errors and they will receive a reimbursement check for their overpayment.

The letter and reimbursement process will differ depending on the employer contract under which a member is covered, and whether the member received their prescriptions at a Group Health pharmacy or a network contracted pharmacy.

  • Members who filled prescriptions at Group Health pharmacies will receive two mailings: a letter followed by a check.
  • Members who filled prescriptions at a network contracted pharmacy will receive one mailing: a letter and check from OptumRx.

We’ve updated our systems to properly process future claims. We’ve also launched a new Web portal that enables our members to see their prescription benefits, formulary, and network pharmacies. The member letters will include the link to this information, encouraging them to take advantage of this new tool.

We are committed to you and to our mutual clients, and we work continuously to improve access to information, care, and services. We appreciate the opportunity to partner with you and are thankful for your representation of Group Health.