John Curry and Molly Janczyk: Questions for Gary Russell

John Curry to Gary Russell, March 7, 2007
Subject: Re: Gary: "Why was my approved prescription denied"?

Gary,
Who deems "inappropriate" in the phrase "the inappropriate prescribing of drugs?" If it is the doctor who made an "inappropriate" decision in his/her professional judgement, then that should be dealt with in a complaint against the physician. If it was not the physician who made an "inappropriate" medical decision concerning which Rx to prescribe... then it was either Caremark or STRS who is making a judgement that the doctor's choice of Rx was inappropriate... this is tantamount to "playing doctor." In this particular retiree's case... the denied Rx was and still is on the STRS/Caremark's list of approved medications.

I realize that millions of dollars were saved by "denying coverage" for Rx that did not meet prior authorization standards but at what cost to the retiree (and other retirees) who badly needed these pharmaceuticals? How many of them went without because they couldn't afford it? The lady who was denied her Rx (in this particular case) was notified of "denial" by mail almost two months after the fact. This lack of timeliness is not a service to retirees.

John Curry
---
Gary Russell to Molly Janczyk, March 7, 2007
Subject: RE: Gary: "Why was my approved prescription denied"?

Dear Molly,

There are a number of drugs that require prior authorization. These are drugs that may cause potentially serious side effects and/or have a high potential for inappropriate use. For example, there are 16 drugs in the ADHD/narcolepsy category that require prior authorization. It is not uncommon for one of these drugs to be prescribed for narcolepsy when other sleep disorders have not been ruled out. Prior authorization is a clinical decision that ensures the appropriate use of a drug.

The inappropriate prescribing of drugs also has a cost impact to your health care plan. Your plan avoided $12 million in drug costs last year by denying coverage for drugs that didn't meet the prior authorization standards. This is a benefit to everyone in the plan since resources are limited.

If prior authorization is denied, then there is no coverage for the prescription. The enrollee may still get the drug; however, he or she will be responsible for the full cost. Prior authorization does not determine which tier a drug is on for the purposes of copayment, prior authorization determines if the drug will be covered.

I hope this helps explain the role prior authorization plays in the administration of your health care plan.

Gary Russell
---
From Molly Janczyk, March 3, 2007
Subject: Gary: "Why was my approved prescription denied"?

Please advise on the following:

Below should be accurate. I don't think STRS does deny any drugs but they decide which are on tier 1, 2 , 3 due to costs, etc. They decide which are to have prior authorization. You can get drugs off formulary at $125. STRS has decided to stop Prescriber Advisor, I thought, where letters are sent to your Dr. re: drugs.

I am not certain if that means Caremark has taken over that role. All pharmacists are supposed to advise of contraindications among meds and advise patients and Dr.'s as Dr's don't always know as much on that issue as pharmacists. But the final decision is up to you and your Dr.

Bottom line: Does Caremark ever deny a drug and if so why?