Comments on: Caremark: Our New Doctor

By: karoli

karoli — Tue, 27 Feb 2007 03:27:10 +0000

redhead468,

yada yada. This I’ve heard over and over again and you’ve even got the Supremes to back you up. Caremark is a contract administrator, they don’t make decisions, they just enforce the contract.

Here’s the problem with the reasoning: Whenever someone needs a prior authorization, the denial is signed by a Caremark physician. Not Blue Cross, not Blue Shield, Caremark.

BC/BS never sees the claim. Caremark shoots the PA for psychiatric meds to their gastroenterologist who checks it against a laundry list without paying real attention to the claim itself and denies it.

The signature on the denial clearly comes from Caremark. No other company.

Don’t sing me the Caremark song about how your insurance provider has the info yada yada, because this is a clear-cut structure of plausible deniability, crafted in such a way that the pockets of the CEOs are lined at the expense of the insureds.

But hey, thanks for the comment.

By: redhead468

redhead468 — Tue, 27 Feb 2007 03:21:53 +0000

I certainly can appreciate all of the info that is included in these posts; however, I feel obligated to advise you that it is NOT Caremark that approves or denies your claims, nor does Caremark make the ultimate decision on what medications are covered. Caremark is a Prescription Benefits Manager (PBM), not an insurance company. A PBM is a company that is contracted by an insurance company to manage the prescription benefits portion of insurance coverage. Management of prescription coverage means administering the benefits according to the insurance plan that you signed up for through your job, an independent insurance agent, or any other venue that you might obtain coverage (Medicare, Cobra, etc…). Caremark does not set the co-pays, it does not handle enrollment into a plan, and it does not decide who or what is covered or how it will be covered. All of this information is given to Caremark by the insurance company you signed up with (Blue Cross Blue Shield, Cigna, Aetna, etc…). Caremark processes the claims according to this information; Caremark advises members (you) how this information applies to them; Caremark fills and ships mail order prescriptions based on the limits set forth by the plan. Keep this in mind: A lot of the information that you seek is included in your plan benefit package or on Caremark’s website. Furthermore, the insurance company should have a website with a wealth of information. As additional ear candy to gnaw on: It is in the INSURANCE COMPANY’S interest to deny your claims one, two, three times or more. Insurance companies (like most businesses) depend on your ignorance, as the consumer, to give up after hitting a brick wall a few times. An insurance company goes out of its way to keep you frustrated with the hope that a claim will never have to be paid.

By: Joy wins! at odd time signatures

Joy wins! at odd time signatures — Sun, 14 May 2006 07:55:42 +0000

[...] Joy sent an update — She was able to get her appeal heard and her meds approved. [...]

By: Joy

Joy — Fri, 12 May 2006 22:48:35 +0000

VICTORY!!!
I have just learned that after my second appeal, Caremark has relented and decided to cover my medication.
This fight has been ongoing since Jan 1. This time my doctor helped me word the appeal asking for a medical review with a physician reviewer (thanks to you, I knew to ask for a physician in the specialty that pertained to my disease).
I also added this link: http://www.chicagotribune.com/business/chi-0605030241may03,1,1705921.story?coll=chi-business-hed&ctrack=1&cset=true This decison by the federal appeals court in Washington on May 3rd says that no terminally ill person can be denied medication because that drug has not beeen approved by FDA.
I am sure that they will continue in the future to try to stop my use of this medication….simply because it is so costly. I am very sick, but if there is strength left, there will be another fight.
I want you to continue to wage this war for your son. Search to see if there are court rulings that back up your appeal. Most court procedures, especially jury trials, are not kind to insurance companies who refuse coverage to thier clients.
Keep up the fight!! I give God the glory for answering prayers and giving me the strength to work on these appeals. I am celebrating!!!
Joy

By: Caremark strikes again… at odd time signatures

Caremark strikes again… at odd time signatures — Fri, 05 May 2006 08:45:31 +0000

[...] I could tell my own tale of woe from last night, but Joy’s is certainly more life-jarring than anything I can tell you. From Joy, who commented on a previous post regarding Caremark’s lack of care: [...]

By: Joy

Joy — Fri, 05 May 2006 01:44:07 +0000

I have also been refused coverage from Caremark recently of a drug that I have taken for 7 years. There are no alternatives that I tolerate. This is a life saving drug in my case. I am in end stage disease.

I am having trouble finding the proper address for filing the appeals. It has been an ongoing process since January. Wherever I send a letter they tell me to do something else. I am getting nowhere.

Any suggestions. Calls do not go anywhere. Just talk to ineffective people.

Thanks,
Joy

By: Don

Don — Tue, 25 Apr 2006 13:13:55 +0000

There is an International scientist concensus statement that warns against the negative media about ADHD. The statement tells of scientists who have devoted their whole life to research in this area and believe that this a developmental disorder that benefits from treatment. To deny such treatment is a misconception about the disease.

By: LFT

LFT — Sat, 11 Feb 2006 02:29:53 +0000

Caremark won’t allow me to have more than 1 month’s worth of birth control pills, either, which means that it is entirely impossible for me to take it properly in the event that i miss two (not that it’s going to happen, but if for some reason i get sick and can’t take them, or something, it’s nice to have a backup) or go on a lengthy trip. so, it seems they’d rather pay for me to have a baby than to allow me a backup pack. what the hell.

By: Caremark Writes at odd time signatures

Caremark Writes at odd time signatures — Wed, 08 Feb 2006 09:01:26 +0000

[...] References: Caremark, Our New Doctor February 8th, 2006 in ADHD, Health Insurance Ripoffs, Health [...]

By: drumsnwhistles

drumsnwhistles — Wed, 08 Feb 2006 08:59:55 +0000

Liz, thank you!

Quixote, yes, and they’re turning quite the profit, too. I truly believe that they are capricious in their denial of benefits and should be made accountable for it.