Caremark: Our New Doctor

Caremark is the gateway to our prescription coverage.  They decide what medications our insurance will cover in part, and what medications will not be covered.  Then there is the “in-between” — those medications subject to “prior authorization”.  I’ve written about this before, but I’m going to do it again since there seems to be a widening disconnect between our doctor, common sense, and our health insurer.  Perhaps they will ‘get it’ if enough people complain.

Sticks has been on the same dose of Adderall XR for nearly 3 years.  In all of that time, the insurance company has managed to duck any co-coverage with me, leaving me with an out-of-pocket bill of $140/month.  There is no other medication that we have tried which has the same efficacy, lack of side effects, and long-lasting effect as this one.  It has enabled him to put all of his attention into personal, musical and academic success.  By that, I mean that it mitigates his hyperactive mind and body and allows him the luxury of focus for the pursuits that he chooses as his pathways to success.

His doctor evaluates him on a regular basis.  We pay for those 10-minute med checks, too.  This year, I decided to push back on the “prior authorization” denial.  After all, they’ve approved ME…why should they deny him?  In order to do this, I have to take him in for a full examination again (we just did this a month ago) and then my doctor has to take time out of his day to write a lengthy appeal as to why this particular medication should be approved for use by my son.

As you read this, keep in mind the following:

1. Adderall XR is one of the top approved medications for ADHD in teens.
2. Studies prove that ADHD is not a “little kid” or “school disorder”.  It is a life disorder that requires management, often through medication and always through life.  Sticks is not at a point yet where, by his own admission, he is ready to manage life without the focus afforded by medication. 
3. We have tried generic medications, cheaper medications, etc.  Ritalin does not work and kills his appetite.  I will not put him on Strattera because I’ve seen too many reports of the possibility that there may be long-term issues that haven’t been studied long enough.  Concerta isn’t even on the “prior authorization” list — it’s denied outright.  He was on it; it worked nicely.  We switched to AdderallXR in the hopes of getting some sort of co-coverage
4. Even with a copayment, we will be out of pocket 40%, so we are still assuming a substantial chunk of the cost

This morning we received a flat denial.  There is an appeals process and we will do it, but I’m furious about it, because by flatly refusing to consider coverage of this medication, Caremark has inserted themselves between me and my doctor.  They’ve done it without so much as an office visit.

My doctor is on the preferred providers list.  I trust him.  He has treated our family for 12 years.  He’s a good, solid, responsive family practitioner who has a large, healthy practice.  He isn’t being sued.  He isn’t a shyster.  He’s a trusted part of our overall healthcare scheme.  Further, Sticks was diagnosed and treated for 2 years by a psychiatrist who specialized in ADHD and was referred back to our family doctor after the firm diagnosis and medication stabilization process.  This wasn’t a random diagnosis — it was carefully and thoughtfully made.

I didn’t hire Caremark to make my doctors’ decisions.  I trust my doctor to make those decisions.  Caremark doesn’t know me, doesn’t know Sticks, hasn’t ever looked at Sticks’ chart, taken his blood pressure, his temperature, treated his ear infections, kid injuries, asthma and coughs, hasn’t watched Sticks march in the local parade as drum captain and applauded that success, hasn’t got a chart 3 inches thick with stuff they’ve done for years and years and years. If any doctor practiced medicine the way that Caremark does, the patients would run as fast as they could to a provider who cared more about them than the bottom line.

Money and medicine don’t always mix.  Simple as that.  But I pay my premiums, have never had a prolonged hospital stay, pay my copayments, and my employer contributes a large chunk, too.  For that, Caremark should be OBLIGATED to respect my doctor’s decisions about medications, treatments, and what is right for my kid WITHOUT QUESTION.  There is no basis for them to become the ‘second opinion’ on this.  We already have a first and second opinion.  Theirs is simply punitive.

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