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Caremark frustrations

Below is a link to a recent phone message from one of Mrs. WhiteCoat’s patients who was “begging” Mrs. WhiteCoat to help her because she was “going crazy with that Caremark.”

Blue Cross Blue Shield Caremark Message

This poor lady is 89 years old, is legally blind, and needs multiple medications.

She can’t get her prescriptions because Caremark believes that she only needs to be taking one of her medications three times per day instead of four times per day as prescribed. The patient doesn’t care. All she knows is that she needs her medications, she can’t get them, and she doesn’t want to “go through this every time.”

She can’t get help through Blue Cross Blue Shield because they “transfer her from one department to the next.” She can’t reach CareMark because the line is “busy busy busy.”

But at least her prescriptions cost less … when they finally arrive.

And if the patient has a bad outcome related to her inability to take medications as they were prescribed by her doctor, who is going to be at fault?

Mrs. WhiteCoat documents in the chart in big bold letters every time places like Medco or Caremark delay filling the prescriptions that she writes for her patients.

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  1. I’m having the same problem. Caremark won’t approved my GERD med for twice a day, only once a day. My doctor wants me to take it twice a day. I ended up getting a second prescription which I have filled through a Canadian pharmacy. What a hassle.

  2. This is why mail order pharmacy, forecasted to be the future of pharmacy, is the bane of the existence of every pharmacy employee who is NOT employed by one of these warehouse giants.

    At least three to four times weekly, we get patients who have never received their medications or have been off of their medications for days (waiting for new scripts to come in) because of the bureaucracy of the mail-order system.

    All so that they can get a month free. Sure, it can add up for some people, but is it worth it?

    Chalk mail order pharmacies up as another “brilliant concept, terrible implication”.

  3. And they will tell the public-“Oh, no. We don’t tell the doctors how to practice medicine!”

    Yes they are when they refuse to follow a written prescription by a licensed doctor.

  4. That is just so wrong!

    Something should be done about these things.

    Why did the ins companies go this route anyway? Must be it saves money. ??

    I am happy with medco thus far …but always prefer supporting and dealing directly with local pharmacist.

    I linked this because it happen to tie in with my current post. Which was funny it happened to me because I found the cartoon the night before …like an omen I suppose. :)

    I hope the lady gets her meds.

    I know that the local pharmacy will provide interim meds and medco goes along with it. there were a couple of times I waited too long to order and then ran out.

  5. A prior authorization can be done to allow for increased dosing of medications. Granted it takes some time; filling out the form and copying the chart documentation showing why the patient requires the increased dosing, faxing the whole thing to the Rx plan, along with up to a 3 business day wait for a response but you will usually get approval for a year that allows the patient to fill the med as prescribed.

  6. They don’t care. They’re out of state, and don’t care. Personally, I and family members had prescriptions through Caremark, and every single person had errors. 3 out of 3 people were dispensed the wrong medicine, multiple times. For myself, I got a drug that had been discontinued, I tried to send it back but they refused to accept it, and they told me “You can speak to a PharmD who will tell you the medicine is still good.” I responded that as a physician, the medicine might be good, but was not indicated in a patient with my condition. Still wouldn’t allow me to return it. Go to a local, non-chain pharmacist, you will get the best service.

  7. There is a foul triumvirate of frustration in the pharmacy side of healthcare: Medco, Caremark, and Wellpoint(Anthem/BCBS). Humana comes in close as well, but it can’t really hold a candle to the level of idiocy Medco or Caremark can pull off. Even the most deranged small businesses, demanding the most obscure things from custom designed insurance plans can’t come up with the bizarre things that Caremark and Medco have instituted for the majority of their members.

    Wellpoint has been on a spree of garbage lately, having disgorged a an enormous amount of their benefits into an outsourced mess. Everything from behavioral health to pharmacy has been farmed out to random companies, from Caremark, to United, to companies no one has ever heard of. This has been handled absolutely atrociously over the last year or so. That is likely the source of the punting about inside BCBS – they’ve cut the section of their plan relevant to prescriptions out of the business and handed it over to Caremark. They’ve also done an absolutely terrible job of it, so no one in the company has any idea what’s going on, or who’s responsible for it anymore.

    Now, from the sounds of it, this patient is hitting a quantity limit of some kind on the plan formulary. If we weren’t talking about this foul triune, we could assume this quantity limit exists for a sane reason – perhaps this is the maximum approved dose of the drug, and higher doses are either not safe or ineffective. Perhaps its a case where the extreme majority of patients only need thrice daily, but a population with special considerations requires a medication four times daily (I’ll admit, I’m having trouble thinking of common meeds that require that frequent dosing in that population group – at least of the sort they’d bother with quantity limits on).

    As another commenter mentioned, this is Prior Auth territory. Since the patient is in the Medicare age group, the most you’re likely to get is a 1 year approval on a quantity. For a sane insurance plan, it’d be a pretty simple matter of a PA – give the insurance company the medical justification. Unfortunately, this is Caremark, and their quantity limits and policies have a reputation for being silly and nonsensical, rather than being based on any real science.

    I can’t offer too much detail on Caremark. They’re one of the few plans I’ve no experience at all dealing with. If this is a Medicare plan, then certain things apply, they’re looking at a mandatory response time of around 72 hours (may vary slightly depending on urgency), they also have to fully review any request you submit – CMS is very harsh on this. You can write a request for coverage determination on a soiled napkin and they still have to review it as though it’s written on the proper form. Of course, in both cases, the doctor has to provide valid contact info, and the information needed to run the request.

  8. “A prior authorization can be done to allow for increased dosing of medications.” Ummm, no. Caremark (who famously quoted hashmd by telling me “We’re not telling your doctor how to practice medicine!”) got all of the paperwork from my doc (which took some time to fill out) and still said no.

    • I’ve spent a good amount time reviewing that paperwork. You’d be surprised how often it’s not filled out properly. By properly, I don’t mean forgetting to dot your i’s and cross your t’s. I mean lacking enough basic information to identify the doctor, the patient, the drug requested or how it’s to be used, let alone any clinical details. On one plan of around 1 million members we get about ~20 a day for crazy doses of narcotics without any notation of why they’re being prescribed say, 640mg a day of Oxycontin.

      For a drug like omeprazole, it’s usually a single page with about 2-3 questions on it. Based on experience with about 40-50 different plans, the main question asked is if once daily dosing was tried, and if it worked. If it didn’t, the pharmacist reviewing the request approves it.

      However, plans vary, and that is for primarily plans that are relatively sane. Caremark is not a company I have dealt with, and they have a reputation as bad as Humana for not going through what they’re sent properly.

      So, first thing to check – was the request sent in with all the relevant information? If not, send it again with it.

      If it was sent with the relevant information, and they denied it, rather than fighting with PA, appeal it. Appeals are pretty easy on something like this. Take the denial, have your MD write about five sentences saying why it’s necessary to have a drug, fax it in. Some chart notes might help as well, but aren’t really necessary.

      Also, if you get your insurance through an employer (or a spouse’s employer), complain to HR – that the insurance denied a legitimate request and ignored your doctor. This is how you get a PBM where it hurts.

      • “So, first thing to check – was the request sent in with all the relevant information? If not, send it again with it. ”

        This was the first thing I thought when I read the bit about “The patient doesn’t care. All she knows is that she needs her medications, she can’t get them, and she doesn’t want to go through this every time.”

        Well…welcome to the world the rest of us live in, where we *do* have to “go through this every time”. I’m sorry that you’re used to sitting on the couch and letting your husband or your son do everything for you, but that doesn’t change the fact that the form is clear about what it needs. I know there’s lots of words and lots of questions, and you just wish you could write “CARMEDONE 4 TIMES ONE DAY” and have the pharmacy know what you meant, but it doesn’t work that way.

  9. My mother, 87, does not even get her medicine through Caremark but her doctor’s office sent her prescription to Caremark. They filled the medicine and sent it to my mother. She opened the box up to see what was in the box since she wasn’t familiar with this company name. I called the doctor’s officce and told them they sent it to the wrong pharmacy. The one I spoke to said to send it back. I packed it up and wrote a letter telling Caremark what had taken place. My mother received a bill in the mail for the medicine even though it was sent back. I called Caremark and was told that we did not follow their procedures for returning the medicine. I was suppose to call them and they would send me a shipping label. No where on the shipping slip or their website does it tell you you must do this.

    Not only did the doctor’s office send a prescription once but twice. The pharmacy did call to say they were about to ship the order. My mother told them not to send it. I called the doctor’s office and told them that it was their fault that we she was being charged for the medicine. They did not agree that it was their fault. I talked to Caremark at least three more times. The last time I was told that the doctor’s office had called and said they had made the mistake but never the less my mother is still suppose to pay for medication she doesn’t have now. With the pharmacy she uses she only has to pay for one of the medications and with Caremark she has to pay for all four of them.
    I told the company she would not pay the bill because it was not her error. She received another statement today.

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