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?)
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?)