From MercuryNews.com:

Study: Drug caps mean sicker patients, no savings

If your health insurance limits how much it pays for prescription drugs each year, your health could be the worse for it.

So say researchers at Kaiser Permanente, who concluded in a sweeping new study that spending caps hurt people with chronic health conditions the most — prompting many sick, elderly patients to skip their medications once their insurance coverage stops.

For diabetics, heart patients and those with high cholesterol, such decisions can be deadly. The researchers found that seniors who faced spending caps were more likely to visit the emergency room, be hospitalized and die than seniors who didn’t.

The focus is on the elderly, but the same is true of anyone taking medication for a chronic condition, physical or otherwise.

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

So much time and effort for something they should have recognized as their legal and moral obligation to do in the first place! Still, I’m so happy that she was able to prevail!

Technorati Tags: caremark, pharmacy benefits

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.

Technorati Tags: caremark, insurance, medication, healthcare reform

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?

Technorati Tags: caremark, insurance, michael rushnak, prescription coverage

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″.

Who the heck is MRUSHNAK, MD?

• 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

…must be the logic that created Medicare Plan D. 

Dr. K’s analysis:

While it seems reasonable to analyze plans based on the drugs you are
on today, the real issue is the drugs you will be on tomorrow. Congress
appears to have allowed companies to be approved vendors without
specific guidelines on what constitutes basic and reasonable coverage.

Once
again, our lawmakers have acted with the courage of the cowardly lion
in Wizard of Oz. But that makes sense because they also have no hearts
and certainly no brains.

Denise is recommending Mad About Medicine and I am too. I mentioned Dr. K back in October, but the URL has changed, so add this one to your blogroll and you won’t be sorry. I love the idea of having an iDoctor but appreciate most that Dr. K thinks bake sales should be reserved for school fundraisers instead of cancer treatment.

WebMD has a bunch of bloggers these days. I got a kick out of Dr. Moser’s Advice for Santa, too.

Technorati Tags: WebMD, DrK, mad about medicine, blog

Blue Cross looks to cut MRI costs

So now Blue Cross has decided to “re-educate doctors”. Oh please, just give me a break and let the doctors practice the profession they spent thousands of dollars and hours to learn.

The last thing anyone needs is more insurance interventions. Once again, it seems that they have taken the concept of “cost containment” and turned it into “profit containment”. Sorry, but if they’d cut 90% of the red tape and administrative costs those MRIs could be done on a much more cost-effective basis.

Just another example of our fine insurance companies ripping off the consumer…AND the doctor.

Blue Cross