Q RE CVS Caremark & brandname meds (U.S.)

Old Hat,

Make sure you read your brochure/policy carefully. Get copies of the formulary.

My insurance has CVS/Caremark on the prescription side.

I get Remicade. I have Medicare. Since it's an infusion Medicare pays first and then BCBS picks up the rest. This year BCBS medical side denied my January and February infusions and sent a letter I needed pre approval thru the medical side. So the medical side finally approved Remicade but we are still wrangling over January and February infusions. (I had to drag in so many doctors and outside sources to get Remicade approved thru the medical side that it was a nightmare. Every doctor on my team had to verify that Remicade had to be administered as trying a bio similar might throw me into a flare that would be life threatening.)

During the medical pre approval process somehow the CVS/Caremark prescription medication side got involved. Even though infusions have been paid thru the medical side and the prescription side is not paying for it out of the pharmacy side, CVS is demanding that I obtain pre-approval thru their side also---and they then refused Remicade. They are demanding I use a bio similar because that's what is available on the prescription side. Name brand Remicade has to have a special authorization because it's so expensive.

Long story short...BCBS medical is telling CVS prescription side to butt out and yet....they won't. They are demanding I use a bio similar. And now I've reached out to the insurance regulators and my congressmen on both sides to try to get help. BCBS medical has said I'm ok. I can get me Remicade infusions and they will be covered.

I don't know if it's just this one CVS prescription medicine agent that will not stop or the whole CVS prescription department that's messed up. I just know that when I call in I usually get this one female prescription agent --like my account has been flagged, and is assigned to that agent every time I call in with prescription questions.

I've had to wrangle with them for VTAMA cream. They were trying to make me take something else and we had to go thru the hoops for pre-approval on that too.

Gotta admit--its been a difficult year. That young lady takes it personal when she has to send me out a pre-approval letter. I swear it makes her cry. The company must love her cause she takes her job seriously and tries to save them as much money as she can.

But on the other side of the debate--Ive got friends that are not experiencing the same hassles. (They have the same insurance) So maybe the insurance companies decided to audit A thru C this year and give those people a hard time...lol ...

Read your medical brochure and your formulary and your prescription brochure carefully. Expect them to follow it to a T and be prepared to advocate for yourself just in case.

Clo

Update on this issue: my RX insurer sent me snail-mail in late June stating that any med having received Prior Auth before July 1, 2024 would be covered under the new agreement with Caremark. SO-- what happened when I tried to get my Colazal 60-day supply due recently? -- The Caremark pharmacy handed me a package of 60-day supply Balsalazide with receipt stating that it was a 90-day supply! I then asked to speak to the pharmacist on duty, who immediately told me that brandname Colazal "is not available"! I had brought along a Colazal capsule for 'show-and-tell', to prove that it does indeed exist, because my RX insurer's last supplier, Express scripts, had been providing it to me for close to 7 years. Then the pharmacist pledged to contact Caremark HQ and present my argument. I also posted to my veteran gastroenterologist, who had intervened in 2012 with immediate help, after several of us then reporting here were informed by our pharmacies in different states that "Colazal was being removed from production". *** Thankfully, the Caremark Pharmacy phoned me a few evenings ago to say that my med was ready for pick-up, and I hurried over there with fingers crossed-- it was finally Colazal!!!! The online pharma record still says "90-day supply" however, though I was given the 60-day supply-- so that will have to get adjusted for my refill dose due in 60 days. [Sigh] Outliers would never believe what obstacles many of us go through to get our needed med, even when our RX dispensing history proves that it still exists AND we still need it. / Old Hat

Post Edited (Old Hat) : 8/25/2024 5:48:27 PM (GMT-5)

Just a thought .. but if mail order thru them is a benefit possibility you might want to consider it.

The pharmacy by me was trying to switch things up. (My main contact for that pharmacy moved to a new job)... And they were trying to swap things out. Sigh ... They got me on 2 if them. I didn't notice til I got home.

So I did reach out to my old contact ( who's now the pharmacy person at the new infusion place I'm hoping to use) and he suggested that work around. It may not work but I'm going to give it a try next time I get my script refilled....

Im still trying to get the 2 fixed that I didn't notice. They don't work as well for me but the pharmacist I spoke with said "it's the same thing" . Aggghhh!!

Clo


Clo

Outrageous, Straydog, that your daughter has to deal with multiple pharmacy challenges while fighting such a serious condition! How insensitive those corporations have become ... it's a terrible trend in the U.S. as Flowers Gal writes above. I did hear a couple yrs ago about an old friend who was always healthy then developed lymphoma in late middle age. Owing to his longtime work he could choose treatment in Switzerland, France, or the U.S., then eventually he posted that treatment in France proved the kindest and most reasonably priced. / Old Hat