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Caremark strikes again…

by Karoli on May 5, 2006

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

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

Joy, I don’t know if I have any answers for you or not. I will say that telephone calls won’t make a difference. I have a Level II appeal in right now for Sticks’ Adderall that hasn’t been denied or approved, and I got that in by mailing a letter explaining why their reasons for refusal are a threat to Sticks’ mental health.

Start with that first “denial” letter from Caremark. That has an address on it for your Level II appeal. Before sending anything again, call Caremark and request a full written explanation of their reasons and criteria for denying your benefits. They are required to provide that in writing and are not allowed to delay it. I received mine within a week of my request.

Once you have that explanation, refute it in writing, point by point. Get your doctors to write a statement explaining the medical necessity and need for a medication that you can tolerate.

Dr. K on Mad About Medicine has a great list of steps to take with consumer advocates to get their attention. And that’s the key at this point…to get their attention.

I hope you’ll come back and update your progress. My prayers are with you.

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Tagged as: Business, Insurance and Benefits

  • reply
    Actually this package they are paying for is years and years of countless research a pbm does to make the most cost effective plan for their client as possible...tons of data...and youre right...we are a claims processor. Its our job to process the claims and administor the benefits your plan wants you to have. We do get deals and such for particular medication, but youre missing the point in that. If we get 20 mg of lipitor at a contracted rate with cvs at 150 bucks for 30 pills, and zocor for 200, then we make that a "preferred" medication that saves your plan (our client) money, and what does that do?..it allows them a more friendly and larger budget to cover other medicaitons. Its your plan that tells us to deny and do what we do...thats what we get paid to do. It;s good business, and if it was your idea, then you would have done it too
  • So basically in an era where health insurance premiums have outpaced inflation by more than 200% you're saying that part of the expense is for our insurance company to hire Caremark to essentially be the benefit denier with no real medical review of the claim?

    I don't buy that. And that's not what the pharmacy benefits contract says either.

    But let's suppose that's true. Is Caremark basically selling their service by saying "Hey, we can deny claims more efficiently than Medco down the street?"

    I don't think so.

    The facts are that this medication has been denied with no factual basis for doing so.

    The facts are that one of the "various other ways" that Caremark makes money is through pharma rebates for promoting one medication over another.

    Is the health insurer a part of the problem? Absolutely. But they're not all of it -- Caremark has at least as much responsibility.

    When you all start denying claims for Viagra I might take you a bit more seriously.
  • get real
    I work for Caremark, and I can tell you that this "service" is the same for any pbm. Caremark does not truly "deny" your coverage. Caremark is contracted on by your health insurance company or your benefits office to adminsiter their plan. Does Caremark get the blame? of course..thats part of the reason as to why we get paid to handle their plan. Caremark doesnt pay for your drugs...your insurance or benefits office does. We make our money in the contract with that client (and various other ways) So when your appeal is denied..keep in mind we are going off the guidlines that either A. your benefits office or insurance company created or B. your insurance company or benefits office adopted these guidelines as a sort of "package" Caremark creates and offers our clients. Caremark only refuses coverage because ultimately thats what we're told to do. We just look like the bad guys and take the blame.
  • Joy
    My physician told me yesturday to contact Caremark and ask for a medical refiew with a physician reviewer. That review would need a response in writing to myself and my doctors. This physician reviewer should state what his reccommendations and reason for denial are. He said that this put the physician reviewer and Caremark on the spot to come up with a solution. He said that 'by law' they have to respond to this particular request.

    Perhaps, you too can do this.

    My prayers go out to your son, also.
    Joy
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