I received my adverse authorization letter (PDF format, personal info redacted) from Caremark today. Their denial says, in part, that “Plan approved criteria requires the patient to have ADHD symptoms in more than one setting…, per MRushnak, MD 01/30/06″.
- A Gastroenterologist
- Medical Director of Horizon Blue Cross Blue Shield
- Presenter at the 2002 aahp.org conference. Topic: “Understanding health plan approaches to promote consumer choice and access. Analyzing the use of emerging technologies, such as electronic physician referral/pre-authorization and e-commerce initiatives, to increase access to and choice within managed care services.”
- Caremark Executive
Yes, a gastroenterologist/executive who works for my health insurer and my pharmacy benefit manager has made the determination that my son does not have ADHD symptoms in more than one setting. This is based upon a series of questions Sticks’ doctor answered via fax. I called and asked his doctor whether they asked about this specifically and he said not only didn’t they ask specifically, he made A POINT of including the fact that the ADHD symptoms were present at home, in school, in leisure and were greatly mitigated by the meds.
So the denial is a flat-out lie. I dare Michael J Rushnak, MD to call me personally and explain his decision. He would have to admit that it’s purely a money decision (NB: Caremark’s stock price is up from about $40/share to $50/share in one year).
I checked the Physician’s Reference to the 2006 Formulary. Adderall XR is listed as a covered medication. The ONLY footnote says generics should be considered first. There is no mention of prior authorization for AdderallXR. Further, if you visit the physician’s portal for prior authorization you’ll see that they do not specifically list those medications subject to PA. There is an extremely vague list of criteria, which could be applied to any medication on the market.
The letter goes on to outline the appeals process and timeline for appeals. Any way I cut it, I’ll be out $140 for this month. Possibly I’ll have no recourse but to continue paying for it. If that’s the case, I will be naming names, finding examples of iniquities and unfair determinations, and periodically reporting here on Caremark’s abuse of discretion, which is what it is.
Here’s why: They approved it for ME. What makes me different? Age is not a defining criteria for this particular medication with regard to “overuse, misuse, or off-label use” (actually, my generation is more likely to fall into this category than Sticks’), I fall into the same “specific patient population” as Sticks, there are no “significant safety concerns” that apply to him which would not apply to me, it is used for the condition it’s intended, and it is “expensive” whether it’s for me or Sticks.
Therefore Caremark has arbitrarily determined that one of us should receive medication and one of us shouldn’t (assuming that we didn’t have the means to pay for it ourselves), with the same set of criteria. That’s an abuse of discretion, Dr. Rushnak.
I’d like to suggest that Dr. Rushnak go back to his specialty and leave the care of my son and family in the hands of our very capable and caring family doctor.
This whole process is just tiring, annoying, and expensive. I admit that I’m discouraged and beyond frustrated. Caremark and Horizon Blue Cross Blue Shield have registered profits of over 50% between 2002 and 2004. I, on the other hand, have gone into the hole to the tune of about $5,000 in out of pocket costs. I want these companies to be accountable for their decisions.
If you have any stories to share about similar abuses, please leave me a comment. If you have suggestions for ways to spread the word about the arbitrary and capricious denials of benefits by Caremark, please leave a comment, too. And if you just want to bash ‘em or set me straight, those comments are welcome as well.
Technorati Tags: caremark, blue cross, prior authorization, ADHD, AdderallXR
References: Caremark, Our New Doctor
