Insurance denied medication

[Samtex]

This seems to be a new twist on an old problem. We all know that insurance companies won't cover certain "expensive" drugs, when their are good alternatives. I can understand their perspective.

We have Blue Cross / Blue Shield which uses Caremark for their drug coverage.
In the past they have covered my Celebrex. We just sent in a new prescription to get a refill. CVS/Caremark said no to the refill. When questioned they said the "insurance company" (Caremark) doesn't view Celebrex as necessary and that another drug should be requested. I think many of us have gone through this. My doctor was informed of the denial and he faxed something back to them requesting Celebrex again but it was denied again. (I don't think it was a detailed "protest")

The odd thing is they do not have a substitute drug listed in their drug list (formulary). In fact they don't even list this family of drugs in their limited formulary on-line. They said their on-line list only shows some of the drugs they cover. They said they have a second, more complete formulary that they will not disclose to their policyholders. (sort of like that double secret probation in Animal House)

They say that the doctor has to come up with a substitute and then submit it to them for approval. I can't understand why they won't offer some guidance as to which drugs they will cover. This seems to me an unnecessary time burden to put on the doctor and me as we go back and forth with them.

When we called Blue Cross they said they have nothing to do with the drug coverage. We needed to talk to the "drug insurance company" (Caremark).

When pressed, Caremark said the doctor could file a "protest". When I called the doctor's office back, they said they usually don't file those because of the amount of documentation required and the limited success they usually have.
They did say they would consider doing it for me but they weren't encouraging.

Has anyone gone through this type of "negotiations" to get a prescription?
(When the drug company won't even give a list of "approved" drugs?)

[Rich_by_the_Bay]

Caremark is a problem child. Your experience is not unusual. They play games, it seems to me. I understand your frustration, as well as that of your physician's office for the unpaid time burden multiplied by hundreds or thousands of patients.

But if you need it, you need it. Your doc needs to come up with an alternative (as you may know, celebrex carries unusual risks usually with little benefit over ibuprofen and similar drugs for most patients, but that's another story).

Good luck with Caremark - ask to speak with a pharmacist rather than a drone.

[youbet]

If I believed the drug was the right thing for me and, like Celebrex, it was not out of my price range, I'd fill the prescription and carry on. You can always maintain pressure on Caremark regarding their overall policy and this situation in specific. Remember, you're not talking about access to this drug. You're arm wrestling over who pays the bill.

I also have Caremark as my drug insurer/provider. They do cover the four maintenance drugs I take, but I don't take Celebrex. Based on your input, I need to go look at their policy on formulary drugs.

What is your doc saying in regard to the question of whether there is another drug he'd substitute for Celebrex that is on the formulary?

[Samtex]

I have an appointment in 2 days to see him anyway. I will bring this up with him at that time. I ran out of Celebrex today, so I am going to try some Aleve and try them.

The main problem however, is that our formulary doesn't show any drugs in that class. (nsaids / COX-2 inhibitors) So it appears it will be a hit and miss till he can come up with something that they allow.

Quote:

Originally Posted by youbet I also have Caremark as my drug insurer/provider. They do cover the four maintenance drugs I take, but I don't take Celebrex. Based on your input, I need to go look at their policy on formulary drugs. What is your doc saying in regard to the question of whether there is another drug he'd substitute for Celebrex that is on the formulary?

[JOHNNIE36]

I think most health care companies will shy away from alot of arthritis drugs. I was involved in the Vioxx fiasco and switched off it after four years. Since Vioxx I have been on Diclofenac Sodium. It works as well and being a generic, is on the WalMart cheap list (less than $10/90 day supply). Ask your doctor if it might be worth a try. I buy a number of drugs outside my health plan because they are cheaper. This includes one from Canadian Meds. I do all this to stay away from "the donut hole".

[FinallyRetired]

Yep, I've had that problem, not with Celebrex or your insurance company, but with Tricare mailorder. They gave me the same story, they can't fill drug X but they can fill a substitute drug Y. When I told them my doc specifically said X they said I could go to the doctor and have him do a reclama.

I went to the doctor and their office said they would do it if I insisted but they've tried that many times before and the insurance company just says no. So I just left it at that, tried Y for a while then said forget it, and paid it out of pocket.

The worst, however, was when I went for a rare appointment at a VA hospital. I don't usually go to them but it was the only facility close to me when I was on a trip. I went through all my meds, most of them just routine drugs used for asthma, and at the end the doc said, sorry, we can't fill any of those, we have substitutes. Fortunately, I still had enough refills left I didn't need to try the subs. Not that I would have cared, if that was my only choice, but I was surprised that the VA would not fill the same brand prescriptions as Tricare, even though they are both gummint pharmacies.

[Ronnieboy]

Quote:

Originally Posted by Samtex I have an appointment in 2 days to see him anyway. I will bring this up with him at that time. I ran out of Celebrex today, so I am going to try some Aleve and try them. The main problem however, is that our formulary doesn't show any drugs in that class. (nsaids / COX-2 inhibitors) So it appears it will be a hit and miss till he can come up with something that they allow.

There is nothing quite like Celebrex as far as COX-2 inhibitors, but there are a ton of NSAIDs. The closest ones to Celebrex are diclofenac, meloxicam, and nabumetone which all have a higher affinity to COX-2 than COX-1, but not as high as Celebrex.

As far as cost goes Celebrex is ($$$$), meloxicam and diclofenac ($) and nabumetone ($$). It will be trial and error, but one could work as good for you as Celebrex does.

I have observed some insurances require that you try and fail 3 other NSAIDs before paying for Celebrex.

As mentioned, talk to your local pharmacist and see what s/he has to suggest then talk to your physician to work out a plan.

Good luck.

P.S. It is almost scary funny that the insurance has a secret formulary that they won't share with the patients that they are trying to 'help'.

[Sue J]

Our new retireee insurance posts it's formulary online. I printed it out and took it to my doctor and explained to her about how we now had a large deductible and would be paying for our own prescriptions. She was very helpful and cooperative in writing all new Rxs and letting me try out less expensive options on the formulary. Makes me wonder why I was originally prescribed such high cost meds.

Our insurer has the step program that if you have already tried the cheaper ones and had a problem you can then get the more costly one. But then again, we're now paying for it with the high deductible so I'm willing to try the less costly one.

For example, I've been on Atacand (for high blood pressure) for a few years. With our previous insurance it cost $360 for 90 days but our co-pay was only $20. With the new insurance Atacand is in their step program. So I'm going to try Losartan (generic Cozaar) which is $152 for 90 days. I'm hoping it works out as well as the Atacand as Atacand was my 3rd med after HCTZ and Lisinopril which both had side effects.

I also take Niaspan ER ($278 for 90 days). Since I have not had any of the dreaded flushing side effect I'm going to try the OTC niacin for about $15 instead.

[Ed_The_Gypsy]

Quote:

P.S. It is almost scary funny that the insurance has a secret formulary that they won't share with the patients that they are trying to 'help'.

They are a business. What ever gave you the idea they want to 'help'?