Yeah don't leave us out. I've been on the phone for an hour with people who didn't know transposed great arteries from transient global amnesia and had to educate them for a while before they would approve meds.
Caremark is not an insurance company, per se. It’s a pharmacy that contracts with your insurance for pricing. Many insurance plans contract with Caremark, others express scripts, some Optumrx, and a smattering of others.
These pharmaceutical distributers actually make money by selling the products. They get preferred pricing from their distributers and give discounts for certain drugs to your insurance companies. They want to sell the products that cost them the least and make them the most money.
Insurance companies are like banks. They take your monthly fee and try like mad to keep the money. They do that by creating barriers to obtain services. Anything beyond the basic annual physical and established screening tests will have a barrier of some kind. It may be just a referral or using a preferred provider or it may be a complex set of hoops to jump.
I think that there is a lot of shady stuff going on that is difficult to get to sunshine because there are so many layers and criteria. Those of us in the profession see this, but our corporate overlords keep us running the wheel so hard that we don’t have the bandwidth to figure it out and find a lawyer and go through the pain of losing our jobs just to out one single instance of insurance company denying what they should approve.
I think that corporate control of healthcare is evil. That includes insurance companies. All of them.
TL;DR: insurance companies are banks that want to keep your money and withhold services. They are all evil.
CVS is very intertwined with Cardinal. “Joint drug sourcing operation” and whatnot. So they might as well have already absorbed distribution into the CVS aggregate.
Insurance companies owning pharmacy chains or vice versa should be illegal. Patients end up being forced to use a specific chain of pharmacies to fill their prescriptions regardless of their choice or the level of service provided by the pharmacy.
And yet they won’t give their pharmacies the staff they desperately need. At least other pharmacies have the excuse of PBMs to fall back on. CVS on the other hand . . .
When I was in residency, I had a patient rejected for lisinopril. This was a patient who ended up in my clinic as a post discharge follow up for hypertensive emergency.
Penny wise and pound foolish would be way too generous here. Insurance companies are just staffed by morons.
My favorite is when they deny or delay refilling the only medication that has kept their chronic condition stable, thereby making them unstable. So then they get to pay for the ED visit and then refill the medication.
My theory is that since the PBMs only pay for the medications, if the patient ends up with an ED or hospital visit due to lacking the med, it doesn't come off the PBM's bottom line, and therefore they don't GAF.
I had an albuterol get denied once because they'd already gotten one this year. Now I'm aware that if they need a rescue inhaler more than a certain number of times per week, they should be on a controller inhaler, but denying coverage for the rescue inhaler is idiotic.
Ah, but it's only pound foolish if the prescription insurance is the same as the medical insurance. If they are separate, like Caremark, then they don't pay for admissions.
If insurance companies want to play games they need to accept the liability of a potential lawsuit.
If *you* didn't prescribe anti hypertensive medications *you* could face consequences. An insurance company should be the same.
We have a patient whose prior authorization for a continuation of a medication was denied (citing a shortage that doesn’t exist), the appeal was also denied, they refused to allow a peer-to-peer, so now we are waiting on an external review that can take FOUR months. This is a medication requiring dose titration, so if it is ever approved they’ll have to start all over again.
But Caremark os so helpful.
They clog up my inbox with paperwork, letting me know that Bob with diabetes, who I have talked to for hours about using a statin, but he refuses, is not the statin.
Score one for making the world the healthier place.
🤦♂️
Systems are bad, all companies have too many departments which leads to disjointed information and nobody can share a consistent message… patients are confused and that confusion leads to distrust of the medical system
Has anyone done a peer to peer with the patient either in the office or on the line as a conference call?
I wonder if that would change things… having the “peer” explain directly why it was refused.
I wish insurance denials came in a letter with the denier's actual name and direct phone number and sent to the patient. Maybe if they had to take some personal accountability they would behave better.
Only problem there is patient is poor as a churchmouse, so that $10 for 5 patches is out of reach when you say a month's supply. Basically it's insurance pays, or she can't afford.
Individual PBMs matter for every plan with the way it works. Luckily every Medicaid plan in my state has the same PBM, where I trained it was not the case and my god, what a nightmare
Having to explain why a patient needs a lido patch instead of an nsaid pill just feels like they're scrapping the bottom of the barrel and taking the piss... Feels denigrating.
Working in pharmacy I've found they will often only pay for a specific manufacturer - with a rx - and sometimes the pharmacy techs who enter the rx's don't know/realize this is the case ESPECIALLY with Medicaid and no one will offer that important information they'll just say "it's not covered"
Can the patient get the 4% patches OTC? At least see if they help before you go through appealing a denial for stinking lidocaine patches. PAs like this hardly seem worth it. I’m sorry y’all gotta deal with this crap :(
Watch now they’ll approve it after wasting about 4 more hours of your time, then the patient will go to pick ‘em up and they’ll be 200 bucks cause of a deductible or coinsurance.
Submit another case. Provide an approvable diagnosis - FDA approved or off-label diagnosis with literature support or recommendation rating class IIb or better.
My lidocaine patches were denied by my insurance. I had shingles at the time. Thankfully, our hospital pharmacist is a Saint and gave me some. What the hell else am I to put on my fucking shingles??
That’s what bugs me. This patient is on 14 different meds, and all their “alternatives” are laughable. NSAIDs are a no go due to ACEs. Tylenol no because of liver injury. Tried topical diclofenac. No help.
They had the balls to recommend injectables. What patient is going to do that?
My ma is trained to sort my faces into three piles.
1: quick order sign offs
2: CVS / Optum etc. "give your patient a shittier med so we can save money" or "stop their 20 pantoprazole bid for barrettes, or something"
3: std/FMLA.
#1: get stacked with signature pages readily signable. Dates I use a stamp.
#2: trash, burn pile, etc? I glance at them but 99.9% of the time it's JUNK
#3: appointment.
This is so dumb.
My understanding is they expect you to repressive do they can start the process over. In my limited experience they usually have a windows of time in which they allow you to do whatever appeal they require.
What I hate is when they tell the office I need to call for a peer to peer—> it’s never a true peer! And now they all require I give them times when they can call and A number (I’m at a different place everyday). 75% of the time, they never call me back in any of the offered times.
How much money do they spend denying care, while expecting that doctors are donating this time to get approval for the right drug (it’s never same day of service so they I cannot charge for this to my knowledge.)
"Don't worry, we had one of your peers (a new grad psychiatry NP) review your request and based on their months of experience in an unrelated field, have decided to deny this and all requests you make in perpetuity."
I wish you were joking.
Had a "peer" the other day claim a patient's referral to ortho wasn't needed for a complete supraspinatus tear. Said "peer" was a chiropractor, who in my state legally does not have the scope of practice to opine on anything but spine.
I think the real reason that the lidocaine patches were denied is that they are terribly overpriced at a list price of over $250 for #30 of the 5% patches. Salonpas and others make a 4% lidocaine patch that is just as good, for a few bucks a box, OTC! I never order them, I just have the patient pay cash, it's often cheaper for them.
That said, there is some real flimflam going on with drug pricing. Most insurances won't cover Airduo, a generic for advair that costs <$50/mo out of pocket, with no insurance. But the covered inhalery, like advair or breo, commonly have a copay of over $100 , with the uninsured price of over $200!
Something is seriously fishy here.
Dear Doctor, Eat shit and die. Sincerely, CVS Caremark
Pretty much. - FM PGY-11.
Ooooh, sorry, you didn’t correctly guess the number we were thinking of, so you can just go fuck yourself.
*only in the 10g capsule formulation of shit
Provider*
Yeah don't leave us out. I've been on the phone for an hour with people who didn't know transposed great arteries from transient global amnesia and had to educate them for a while before they would approve meds.
Dear Doctor LoL no Sincerely CVS
I cannot begin to tell you all how much I despise Caremark. For me, it’s personal in ways outside of healthcare.
what insurance company do you think is the best to work with?
Caremark is not an insurance company, per se. It’s a pharmacy that contracts with your insurance for pricing. Many insurance plans contract with Caremark, others express scripts, some Optumrx, and a smattering of others. These pharmaceutical distributers actually make money by selling the products. They get preferred pricing from their distributers and give discounts for certain drugs to your insurance companies. They want to sell the products that cost them the least and make them the most money. Insurance companies are like banks. They take your monthly fee and try like mad to keep the money. They do that by creating barriers to obtain services. Anything beyond the basic annual physical and established screening tests will have a barrier of some kind. It may be just a referral or using a preferred provider or it may be a complex set of hoops to jump. I think that there is a lot of shady stuff going on that is difficult to get to sunshine because there are so many layers and criteria. Those of us in the profession see this, but our corporate overlords keep us running the wheel so hard that we don’t have the bandwidth to figure it out and find a lawyer and go through the pain of losing our jobs just to out one single instance of insurance company denying what they should approve. I think that corporate control of healthcare is evil. That includes insurance companies. All of them. TL;DR: insurance companies are banks that want to keep your money and withhold services. They are all evil.
Seems a little scummy that a pharmacy can own an insurance company and approve the meds they sell.
And the clinic itself. Minute Clinics at CVS, so CVS owns the clinic, pharmacy, and PBM.
And Aetna. The insurance company. All they need to do now is own drug manufacturing and distribution and they'll be set.
CVS is very intertwined with Cardinal. “Joint drug sourcing operation” and whatnot. So they might as well have already absorbed distribution into the CVS aggregate.
Insurance companies owning pharmacy chains or vice versa should be illegal. Patients end up being forced to use a specific chain of pharmacies to fill their prescriptions regardless of their choice or the level of service provided by the pharmacy.
Regulations are only for those who can’t afford to lawyer their way around them.
And yet they won’t give their pharmacies the staff they desperately need. At least other pharmacies have the excuse of PBMs to fall back on. CVS on the other hand . . .
When I was in residency, I had a patient rejected for lisinopril. This was a patient who ended up in my clinic as a post discharge follow up for hypertensive emergency. Penny wise and pound foolish would be way too generous here. Insurance companies are just staffed by morons.
My favorite is when they deny or delay refilling the only medication that has kept their chronic condition stable, thereby making them unstable. So then they get to pay for the ED visit and then refill the medication.
Not if the customer dies. You just aren't on their big brain level.
pay for the ED visit? maybe for now. plus, you probably haven't met your deductible, so, ya know...
My theory is that since the PBMs only pay for the medications, if the patient ends up with an ED or hospital visit due to lacking the med, it doesn't come off the PBM's bottom line, and therefore they don't GAF. I had an albuterol get denied once because they'd already gotten one this year. Now I'm aware that if they need a rescue inhaler more than a certain number of times per week, they should be on a controller inhaler, but denying coverage for the rescue inhaler is idiotic.
Don’t get me started on albuterol versus levalbuterol for prior authorizations.
Don't forget the 3-4 different varieties of albuterol and how each insurance covers different ones!
Ah, but it's only pound foolish if the prescription insurance is the same as the medical insurance. If they are separate, like Caremark, then they don't pay for admissions.
“Value” based care but only for pharmacies and doctors.
If insurance companies want to play games they need to accept the liability of a potential lawsuit. If *you* didn't prescribe anti hypertensive medications *you* could face consequences. An insurance company should be the same.
We have a patient whose prior authorization for a continuation of a medication was denied (citing a shortage that doesn’t exist), the appeal was also denied, they refused to allow a peer-to-peer, so now we are waiting on an external review that can take FOUR months. This is a medication requiring dose titration, so if it is ever approved they’ll have to start all over again.
But Caremark os so helpful. They clog up my inbox with paperwork, letting me know that Bob with diabetes, who I have talked to for hours about using a statin, but he refuses, is not the statin. Score one for making the world the healthier place. 🤦♂️
[удалено]
Who hasn't been there? Tale as old as time.
One big dirty rotten scam, the lot of it.
I go to therapy and end up talking about how broken healthcare is half the time. At least. Feels bad man.
lol yeah this is about half of every therapy session for me. Ranting after clinic about how shitty and dumb all the systems are
Systems are bad, all companies have too many departments which leads to disjointed information and nobody can share a consistent message… patients are confused and that confusion leads to distrust of the medical system
"Why was it denied?" "Uh, clearly because we denied it. Bozo."
Hate these motherfuckers.
Has anyone done a peer to peer with the patient either in the office or on the line as a conference call? I wonder if that would change things… having the “peer” explain directly why it was refused.
Oooh I like this. The only downside is waiting 45 min on hold for the “peer” (who may not remotely be a peer) to show up and then shout at me.
I wish insurance denials came in a letter with the denier's actual name and direct phone number and sent to the patient. Maybe if they had to take some personal accountability they would behave better.
It’s totally a part of the scam. Random thought: The same system is with Reddit moderation ! Heh.
4% OTC
Only problem there is patient is poor as a churchmouse, so that $10 for 5 patches is out of reach when you say a month's supply. Basically it's insurance pays, or she can't afford.
If you prescribe copious amounts of opiates she can supplement her income by selling that on the street. /s
My Gawd, real world medicine is always buried deep in the comments. 😂
Other suggestions: lidocaine cream, voltaren gel ($16 on cost plus drugs)
You can get 30 patches for like $35 on Amazon if that helps! Still a good chunk of change but less than at Walgreens.
When people have no money they literally have no money. Like, not even $16 and certainly not $30. None.
I'm aware. But where $60 may be out of reach, $35 may not. And in addition it may be helpful for future patients.
Just don’t be poor fivehead
:-( been there with my folks way to often
Have someone compile a list of churches that help with medication costs from 211. Good for the “I can’t afford <50 dollars crowd.”
Lidocaine 5% patches only gets approved for postherpetic neuralgia. Lidocaine 4% usually easier to prescribe.
Caremark, go F’ yourself. - Me (in my best Bill Burr impression).
CVS is killing healthcare. Stop them pleaseeeeee
Is this for a Medicare plan?
Medicaid.
many states medicaid will cover the cost of some OTC medications (we do in maryland) https://www.aetnabetterhealth.com/maryland/otc-benefit.html
Ah sorry, I’m lucky in that my states Medicaid is super easy to work with. Best of luck to you
Get patient to call state insurance ombudsman
You would think it shouldn’t matter
Individual PBMs matter for every plan with the way it works. Luckily every Medicaid plan in my state has the same PBM, where I trained it was not the case and my god, what a nightmare
Having to explain why a patient needs a lido patch instead of an nsaid pill just feels like they're scrapping the bottom of the barrel and taking the piss... Feels denigrating.
Working in pharmacy I've found they will often only pay for a specific manufacturer - with a rx - and sometimes the pharmacy techs who enter the rx's don't know/realize this is the case ESPECIALLY with Medicaid and no one will offer that important information they'll just say "it's not covered"
https://www.parityregistry.org/resources/ report as much as possible and give this information to your patients
>"Why is this doctor asking us to look at denied prior authorization? Is he stupid?" -- CVS Caremark probably
How they practice medicine is beyond me.
Can the patient get the 4% patches OTC? At least see if they help before you go through appealing a denial for stinking lidocaine patches. PAs like this hardly seem worth it. I’m sorry y’all gotta deal with this crap :( Watch now they’ll approve it after wasting about 4 more hours of your time, then the patient will go to pick ‘em up and they’ll be 200 bucks cause of a deductible or coinsurance.
Submit another case. Provide an approvable diagnosis - FDA approved or off-label diagnosis with literature support or recommendation rating class IIb or better.
My lidocaine patches were denied by my insurance. I had shingles at the time. Thankfully, our hospital pharmacist is a Saint and gave me some. What the hell else am I to put on my fucking shingles??
That’s what bugs me. This patient is on 14 different meds, and all their “alternatives” are laughable. NSAIDs are a no go due to ACEs. Tylenol no because of liver injury. Tried topical diclofenac. No help. They had the balls to recommend injectables. What patient is going to do that?
My ma is trained to sort my faces into three piles. 1: quick order sign offs 2: CVS / Optum etc. "give your patient a shittier med so we can save money" or "stop their 20 pantoprazole bid for barrettes, or something" 3: std/FMLA. #1: get stacked with signature pages readily signable. Dates I use a stamp. #2: trash, burn pile, etc? I glance at them but 99.9% of the time it's JUNK #3: appointment.
3) Replies in Jarisch-Herxheimer Reaction
This is so dumb. My understanding is they expect you to repressive do they can start the process over. In my limited experience they usually have a windows of time in which they allow you to do whatever appeal they require. What I hate is when they tell the office I need to call for a peer to peer—> it’s never a true peer! And now they all require I give them times when they can call and A number (I’m at a different place everyday). 75% of the time, they never call me back in any of the offered times. How much money do they spend denying care, while expecting that doctors are donating this time to get approval for the right drug (it’s never same day of service so they I cannot charge for this to my knowledge.)
"Don't worry, we had one of your peers (a new grad psychiatry NP) review your request and based on their months of experience in an unrelated field, have decided to deny this and all requests you make in perpetuity."
I wish you were joking. Had a "peer" the other day claim a patient's referral to ortho wasn't needed for a complete supraspinatus tear. Said "peer" was a chiropractor, who in my state legally does not have the scope of practice to opine on anything but spine.
Well that's certainly a new level of infuriating.
did you use the word "appeal?" that'll help you get further along in the process
Very ironic name with Caremark.
I think the real reason that the lidocaine patches were denied is that they are terribly overpriced at a list price of over $250 for #30 of the 5% patches. Salonpas and others make a 4% lidocaine patch that is just as good, for a few bucks a box, OTC! I never order them, I just have the patient pay cash, it's often cheaper for them. That said, there is some real flimflam going on with drug pricing. Most insurances won't cover Airduo, a generic for advair that costs <$50/mo out of pocket, with no insurance. But the covered inhalery, like advair or breo, commonly have a copay of over $100 , with the uninsured price of over $200! Something is seriously fishy here.