But Gary -- What about Question no. 2??

John Curry to Gary Russell, April 9, 2007
Subject: Re: Gary, I still haven't received an answer!

Gary,

I thank you for getting back with me re. the process that Caremark is supposed to adhere to concerning prior authorization. This will give the retiree an outline of the procedures involving the pre-certification process. This will hopefully clear up some confusion and misunderstandings. It will also serve as a "checklist" (so to speak) so that retirees will know what to look for and, in the event of troubles, will know who is not being responsible.

Gee, I almost was ready to withdraw the "We, Gary, are getting nowhere" statement in my March 23 letter to you but...... I can't seem to see where you got back to me with an answer to the second of two questions in that same March 23 letter. Here it is again - I, and others, will be eagerly awaiting your answer(s) to that unanswered question:

"2. Who is legally allowed to come to STRS and view our contract (in its entirety) with Caremark...are STRS Board members....are STRS retirees...is the general public?"

I'm really not trying to be a pain in the butt.... I am also asking questions that other retirees, for whatever reasons - and I've heard many, simply want answered but don't have the nerve to ask. I usually tell them, "What are they going to do, fire me?" Once again, Gary, please don't forget Question #2. Thank you.

John

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From Gary Russell, April 9, 2007
Subject: RE: Gary, I still haven't received an answer!

John, I wanted to get back to you regarding the process for prior authorization with Caremark to clear up any confusion. The contract with Caremark does not specify a timetable for contacting the doctor's office; however, there is a process that Caremark adheres to.

First, 60 days before a prior authorization is set to expire, Caremark mails a letter to the enrollee notifying him/her of this so that the enrollee can begin working through the process with his/her doctor to ensure that there is no disruption in the filing of prescriptions.

The following process is used for filing a drug that is subject to prior authorization. This assumes the enrollee didn't work with the doctor during the 60-day window provided for renewing the prior authorization.

At mail order, the prescription would be rejected due to needing prior authorization. The mail center would then fax the doctor's office within 24 hours. If there is no response from the doctor's office after three days, the patient is sent a letter explaining that Caremark is seeking information from the doctor. If the doctor's office has still not responded after six days, the prescription is denied and a letter is sent to the patient and the doctor. The doctor can still seek prior authorization after this point and Caremark will reopen the case.

At retail, the prescription would be rejected for prior authorization and the pharmacist will direct the patient to Caremark or the doctor. If the patient calls Caremark, the Caremark representative will advise the patient to have the doctor call Caremark to get the prior authorization approved.

This process is really driven by how responsive the doctor's office is to Caremark. My reason for pointing out the number of cases that get escalated is to demonstrate that the process is working. Given that very few cases are escalated, it shows that the doctors are working well with Caremark to get these prescriptions authorized when appropriate and when the prior authorization is not approved, appropriate alternatives are being found.

Gary