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CVS Caremark Complaint - Wont even follow their own written polict
CVS Caremark Complaint

CVS Caremark Complaint


Wont even follow their own written polict

I'm writing today for my wife. She is 55, and her endocrinologist has prescribed her hormone replacement therapy. The medication is not available in a commercial form (it's a small percentage of the lowest available commercial form), so it has to be made by a compounding pharmacy. Which is specifically covered in my insurance coverage.

We have submitted it, meeting Caremark's own exact criteria (I have their own internal instructions on how to process compound medications. Which explicitly directs the Caremark employee: "Change the compound indicator to indicate that the prescription is a compound" or it will not process correctly, and the insured will not be properly reimbursed.

Our insurance policy for the medication covers it at a 60% deductible, and the EOB we received clearly shows the 40%' eligible reimbursement, but they wont send the check, because it's being interpreted as a "name brand", which our policy and Caremark's own internal definition defines as a compound.

We are not able to afford the medication at 100% (the 60% deductible requires many PB&Y sandwich dinners to purchase, but it makes her feel better, so we make due).

I'm retired (100% disabled) from GE, but all they will do is shrug their shoulders. And our insurance commissioner doesn't work on individual cases.

I'm sure the "mistake" is because of that specific instruction to change the software to "compound". But I can't even get anyone, a pharmacist, say, to review the claim.

I have the PDF policy documents showing what I have claimed. .GE is paying the same amount, either way but Caremark is keeping the 40% I'm due. I'm sure a neutral arbitrator could straiten this out, but for some reason, I'm not being offered this option

We really need help here. GE's policy of allowing Carmark to self-police is preventing my wife from getting her needed medication UN-necessarily. They are just saying no because they can. They are just being bullies.

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HowDareThey says: (3 years ago)
Hi, I am so sorry to hear that you are having this problem. The exact same thing has happened to my wife, except that they had agreed to cover the prescription for 3 months. That time has expired and, after my doctor and the pharmacy followed every single step required, have officially denied coverage. They give many ludicrous reasons for this denial. In one instance, the CUSTOMER SERVICE agent told her DOCTOR that the prescription is medically unnecessary and that "most women don't have this issue". Yes, you heard it right: the person answering the phone knows than a licensed medical professional.

I am drafting and will submit an official complaint to my state's insurance commissioner. I hope Caremark is reading this, although I suspect they are too busy denyng coverage for other patients' medications - some a matter of life and death, if the reviews are even slightly true.

In addition, I plan to spend the next few days faxing their CEO, board and anyone else I can find and will lodge abother complaint through my employer (who provides Caremark as the only option for prescriptions).

If you can't get them to comply, I would recommend we all flood our local commissioner offices with complaints so this can be put to bed once and for all.

Lastly, as regards compounds specifically, I would recommend you do some searches on Caremark and ExpressScripts. Internal documents have been released that show a systematic plan to stop covering compounds by making the process practically impossible - particularly as regards the "ingredients".

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