More on Caremark denying medication to a retiree

From John Curry, March 6, 2007
Subject: Fwd: Why was my approved prescription denied? (Part III) & an almost 2 month delay for notification by mail of denial

The letter below is being shared with the permission of the author.

This STRS/Caremark "Rx covered" retiree is insuring her spouse through a non-STRS healthcare provider. Food for thought: Why should it take almost two months to be notified of an Rx denial? Is Caremark/STRS playing doctor? Is "Urgent" the magic word that you must remind your physician to use so that you will be assured that you will get your medications that your very own physician deems necessary?

I find it interesting that STRS still is contracted with Medco for their (our) employees' prescription needs considering the fact that STRS recently successfully sued Medco in 2005 (another PBM) and is to receive millions of dollars in that court-ordered award (see that article below the STRS retiree's letter that follows). Possibly we are still contractually obligated to Medco... then again, maybe we aren't. I wonder if there are other STRS retirees who have waited almost two months before receiving their "denial" letters while they were looking forward to receiving their dearly needed medications? John

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Hi John,

I did talk to Brenda Foster on Monday. She is very knowledgeable, and I enjoyed talking to her.

She told me to have my doctor to file an appeal and indicate that I have no additional sleep disorders or mental disorders. My doctor is to write URGENT on the form, and I should be approved in 72 hours. She said what happened was that my doctor checked the box NO about no additional disorders, but she didn't add write this on the lines next to the box. Brenda did say that in previous years, my doctor had checked the box NO and wrote additional notes about "no need for additional testing".

Again, she told me that the prior authorization starts with Caremark bringing the medication list to STRS. The STRS staff discusses with Caremark why there is a need to add drugs to this list.

So, Caremark told me that I was denied because I needed additional tests, and STRS said that my doctor can take care of this through an appeal. I did receive my letter of denial on Monday for this prescription that I sent 1/08/07. It took 2 months for them to notify me. This letter states I am denied because "other sleep disorders or mental disorders have not been ruled out". DSS RPh 02/26/07. The participant (me) can still purchase the drug, however, she will be financially responsible for the full cost.

I know that one of the other drugs that I was prescribed would cause me to have additional tests because I don't have Alzheimer's, and before I could have the drug, I would have to have this disease ruled out. I'm not sure that after all of this, my doctor could prescribe this for me.

I did email Medical Mutual about the tests, but I haven't received a reply.

I did ask what STRS pays for my HC; it is $488 and I pay $163...total $651. As I told you my husband's premium is $355, and this is not a group rate. He does have a higher deductible, all doctors and hospitals accepted, most drugs are $90 or less, and I haven't encountered any "prior authorizations".

I also asked what insurance coverage STRS employees had, and it is Medco. I wish I had asked if STRS ever says NO to Caremark's "prior authorization". I'll let you know about the results.

(Name withheld for privacy reasons)

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Jury rules in Medco contract dispute
Memphis Business Journal - December 19, 2005

A Cincinnati court awarded $7.8 million to the board of the Ohio State Teachers Retirement System in its dispute with Medco Health Solutions Inc.

Medco said it will appeal the award.

The allegations made in the case were related to agreements the retirement system first signed in 1993, when Medco began providing pharmacy benefit services to the system's 430,000 retiriees and beneficiaries.

The Hamilton County, Ohio, jury handed down a decision against Medco related to non-contractual duties stemming from the business relationship bewteen Medco and STRS, according to a press release issued by Medco Monday.

STRS had accused Medco of pocketing $55 million in drug-maker rebates as well as charging $49 million in unwarranted prescription-dispensing fees from 1993 through 2001.

The Medco release said plaintiffs were seeking more than $300 million in damages, but the Hamilton County, Ohio jury rejected allegations that Medco breached its contract relating to mail-order dispensing fees. The jury was unable to reach a decision on whether Medco breached its contract related to a rebate-sharing agreement. In November, the judge in the case dismissed portions of the lawsuit due to lack of evidence.

Medco general counsel David Machlowitz said the evidence supported complete vindication for Medco.

"Although the award was a fraction of the claim made by the plaintiffs, we believe there are multiple grounds for Medco to successfully reverse this decision on appeal," Machlowitz said. "Medco's conduct was appropriate, legal, and professional, and in accord with our contract, which served the best interests of the state retirement system."

In a separate action, the jury cleared co-defendant Merck & Co. Inc. (NYSE:MRK), Medco's former parent company, of tortious interference.

Based in Franklin Lakes, N.J., Medco (NYSE: MHS) manages prescription drug benefit programs and operates a mail order and Internet pharmacy. In August it acquired Memphis-based Accredo Health Inc. for $2.2 billion to form the nation's largest specialty pharmacy.