Caremark Update

by Karoli on February 17, 2006 · 1 comment

Dr. Michael J Rushnak decides there is no ground to advance a second appeal. Denied categorically. Read this: Psychiatric medications were denied by a gastroenterologist who hasn’t practiced medicine actively in 2 years.

All appeals are now exhausted, and so I acquiesced to out-of-pocket expense for Stick’s AdderallXR. I got the 90-day supply so I could save $60.

Here’s the balance sheet as of 2/15/06:

My Expenses:

Premiums paid by me since 1/1/06: $600
Premiums paid by my employer: $450
Covered meds subject to deductible: $100
Non-covered meds which do not count against deductible nor do they qualify for negotiated discount: $364.15
Co-payments for doctor’s appointments to cover med check and appeal strategy: $50
Total out of pocket in the past 45 days: $1,564.15

Their Expenses as of 2/15/06:

Coverage for 2 doctor’s appointments: $90
Covered Prescriptions: 0
Total: $90

Blue Cross/Blue Shield/Caremark’s Net Profit On Me To Date: $1,474.15

There is lots of press about the health care crisis in this country. Yes, there is a crisis, but it’s entirely different than what being reported. Do the math, figure the profits, factor in the 75% of bankruptcies due to medical expenses and it becomes pretty obvious that the crisis is rooted in the unbridled freedom that insurance companies have to pay or not pay claims.

There isn’t one thing in their contract that specifically explains what is and what is not subject to their gastroenterologistical expertise when it comes to prescribed psychiatric medications. The crisis is that insurance companies are overriding trained physicians’ judgments on patients they don’t even know in order to boost the bottom line. 50% net profit increase over the past 2 years for them; another $5-6,000 in the hole this year for me.

If their decision were actually medically sound, it would make more sense. But consider that they approved my prescription on the first round without question despite my age (47), my gender (F), and my history of being a smoker. However, that is the only medication I take and I have my 4 visits per year to verify my cardiovascular fitness to take it. Still, on the current profile I should be a sure candidate for denial if a decision were being made with medical criteria.

On the other hand, Sticks has allergies and takes Zyrtec to control them. He’s finally outgrown the EIB (exercise-induced asthma) he had when he danced, but the allergies are serious. However, in his favor, he is 16, has excellent cardiovascular health, is not at risk for other health conditions, and doesn’t fall into the black box warnings by the FDA. (I do.)

It seems my doctor is right. You get one med approved, and the rest had better be formulary or forget about it. It is purely a MONEY DECISION and in no way, shape or form a medical decision.

So what now? Should insurance companies be allowed to run roughshod over accepted medical principles of practice? Why should they have that influence over a physician’s prescribed course of treatment?

What do you all think? Should I just acquiesce, or push harder? And what course should I follow if I decide to push back?

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