Is Caremark out to make us too sick to fight their actions? And who will help us at STRS? Where is the ombudsman?

From John Curry, March 01, 2007
Subject: Fw: Approved drug denied

Note from John: The author of the letter below had her name removed from this general distribution for privacy purposes. Gary Russell now has her name and hopefully will rectify this situation.

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From: (Name withheld due to distribution to others) Thursday, March 1, 2007
Subject: Approved drug denied

Hello Mr. Russell,

My name is (name withheld due to distribution to others). I called earlier today and left a message because you were in a meeting. I have read many of your answers about our health care on the CORE website.

I have the sleep disorder, narcolepsy. I tried for 25 years to get a correct diagnosis. I was then 28, and now I am 58 years old. I have been to the best doctors and facilities in Ohio. I even told the doctor at OSU what I thought I had, but he told me it wasn't. In 2000 I finally got a diagnosis after many tests. The medicines have to be customized to fit each person because all do not have the same symptoms. At last my doctor found the correct combination of medicines that has allowed me to have a life for the last 5 years.

Now Caremark and STRS are denying this drug. In January I followed the correct steps with prior authorization. I kept waiting for this approval, but Caremark didn't let me know that I was denied. I called Caremark only to be told that my doctor did not submit the request. I know this is not true because I received approval for my other medicines. I asked my doctor to resubmit the prior authorization request again. But this time Caremark had to send a fax stating that they did receive the request. Now that it is February, I am told a month later that I was denied. This same thing happened in January '06 and April '06 with the same drugs. There is absolutely no kindness when dealing with Caremark.

A Caremark rep could not tell me the main person/the person in charge/a contact person who made this decision for me. She just kept telling me that it was STRS and a planning committee from Caremark. I know that someone is always in charge. I consulted my STRS health care booklet for '06 because the information on the '07 benefit sheet would have been noted if there was a change. PROVIGIL was still an approved/prior authorization drug.

I was told that my doctor could appeal the decision, and she has, but we know that will take weeks. Here's the sad part...I was told that in order for me to continue with the drug, I would have to have additional tests that would "rule out any other sleep disorder" or that what I have does not "stem from a mental disorder" Evidently someone does not know about testing....I have had and can produce 25 years worth of tests...every part of my body has been hooked up for some test. What would Medical Mutual think about the thousands of dollars that this would cost for the unnecessary testing that my doctor doesn't think I need.

Now, remember my doctor has prescribed this same medicine for me for 5 years, and I have had no problem. I know that I can't live a "normal life" without medication. What does STRS and Caremark want to provide for me?

I have had 2 approved prescriptions denied in the last year, and I gave up because I was again told that I would have to have many tests done in order for Caremark to allow me the drug. I called STRS about these drugs...STRS blamed Caremark and told me to call them...I did and they blamed STRS. Another run-around? I called the STRS rep again and told her that I didn't read in my booklet about the constraints that Caremark indicated. She said to me, "well, we can't put everything in the booklet".

Today, I am tired because I am missing my medicines, and I am tired of the SCAMS and jumping through hoops for STRS. I have read your helpful information to others, and I think you can guide me in finding an answer to my medication problems.

Thank you,

(name withheld due to distribution to others)