John Curry and Gary Russell on denial of approved prescription

John Curry to Gary Russell, March 8, 2007
Subject: Re: Gary: "Why was my approved prescription denied"?
Gary,
I thank you for the background and divulging that it is Caremark that makes
the determination re. prior authorization and/or denial decision - the
retiree (in this case) was told by Caremark that it was STRS who made the
denial of the prescription. A point not addressed is that the notification
of denial to retiree (in this retiree's instance) came in the mail almost
two months after the denial was determined. This delay is unconscionable.

What can you relate as to the timeliness of the notification of denial by
mail (or by other means)... what "timetable" is Caremark held to for this
notification? Thank you for your response.

John
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From Gary Russell, March 8, 2007
Subject: RE: Gary: "Why was my approved prescription denied"?

John,

Caremark administers the prior authorization program and makes the determination through consistent protocols that are based on clinical decisions. This program is a benefit to both the retirees who are prescribed the medications requiring prior authorization by assuring better use of medication and a benefit to all enrollees by assuring that your health care dollars are spent wisely.

Perhaps a couple of examples will help you understand the benefit of prior authorization. As I noted in my earlier email, there are drugs on the approved list for narcolepsy that require prior authorization. It is not uncommon for a doctor to prescribe a drug to help the person stay awake during the day which treats the symptom but not the problem. The symptom of not being able to stay awake during the day may really be the result of a sleep disorder that hasn't been identified through appropriate tests. The prior authorization process looks to see if those tests have been administered to rule out a root cause of not being able to stay awake during the day. The patient is better served by this. Another example is the prescribing of Lamisil for toenail fungus. Lamisil is only effective if the discoloration of the toenail is a result of fungus; however, doctors will prescribe this medication to see if it works without first testing to see if there is fungus present. If fungus is not present, Lamisil will have no impact and the patient would have taken an unnecessary medication and your health care plan would have paid for an unnecessary medication.

I want to assure you that no one is denying coverage just for the sake of saving money for your health care plan. No associate at STRS Ohio is better off as a result of a drug being denied to a retiree. The prior authorization program is there to help ensure that drugs are being used judiciously and as a result that we aren't spending your health care dollars unnecessarily.

Gary Russell