Push back! Good for you! Our insurance has decided to double our co-pay for non-generic medications, when the meds we really need don't come in generics. Highway robbery!
I'm sorry your son can't take Concerta. It's worked really well for Klaus.
liz
· 3 years ago
I nominated this post to Grand Rounds, and it is in.
Your story is repeated heartbreakingly many times, in so many different ways, all the way up to life-threatening and beyond. I find it sad, in a way, that you feel the need to say you pay plenty yourself. This should be totally irrelevant, but our system is so focused on chasing down freeloaders, instead of helping the sick, that I can understand your feelings. And the really stupid part is that chasing non-existent freeloaders costs money. All the effort Caremark spent on not-helping you would have probably paid for a year's worth of medicines. But I'm sure this way it looks better to the shareholders. I mean, why would a for-profit company care about profit, right?
drumsnwhistles
· 3 years ago
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.
LFT
· 3 years ago
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.
Don
· 3 years ago
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.
Joy
· 3 years ago
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
· 3 years ago
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-0605... 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
redhead468
· 2 years ago
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.
karoli
· 2 years ago
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.
All Comments
I'm sorry your son can't take Concerta. It's worked really well for Klaus.
http://sciencepolitics.blogspot.com/2006/02/gra...
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.
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
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-0605... 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
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.