As if our health care “system” wasn’t already complicated enough, here’s example No. 9,572.
I spent the better part of one year trying to ask a prescription drug provider one simple question about my prescription. Even as someone who works in health policy and with advocates on my behalf, I kept getting the run-around.
Unfortunately, as I found out firsthand, big conglomerates — in this case, CVS Health — make profits by keeping the system complicated, bureaucratic, and opaque. But (eventually) I found out there’s a simple solution: returning to good, old-fashioned cash transactions.
Mail Order Madness
The saga started last summer, when my physician prescribed a maintenance medication to prevent a recurrence of kidney stones. My doctor sent a prescription to CVS Caremark, requesting a 90-day mail-order supply of the drug. CVS is the pharmaceutical benefits manager (PBM) that administers my prescription.
When it arrived, I received the following note:
We filled your prescription with a smaller quantity than what your doctor prescribed. Your prescription plan has limits on the amount of your medication it will cover. We filled your prescription according to these limits. [Emphasis original.]
For the better part of 12 months, I communicated with CVS staff, trying to figure out the reasons for this decision. I also asked a representative from the District of Columbia’s Office of Health Care Ombudsman to investigate on my behalf. Every time my physician prescribed a 90-day supply of this medication, CVS Caremark sent me a 30-day supply of the drug, along with the same note described above.
A few weeks ago, I finally spoke with a CVS representative who could tell me the reason. While my prescription plan covered the drug, it did not cover it as a maintenance medication. This explained why CVS Caremark kept lowering the medicine supplied from 90- to 30-day supplies.
The representative informed me I could use an exceptions process, through which my physician could send a form to CareFirst (my insurer) providing clinical justification to use the drug for maintenance purposes. If approved by CareFirst, then CVS Caremark would honor the 90-day prescription, and provide me with a three-month supply of the drug going forward.
This annoyed me, because I had mentioned the exceptions process (which I know about from working in health policy) while speaking to CVS personnel last summer. That individual never provided me the information I had asked for, which could have saved me months of hassle.
I contacted CVS’ corporate office to ask two simple questions: why did the notices I received refer to “your prescription plan” — a wording that seems deliberately vague as to whether my insurer (CareFirst) or the PBM (CVS Caremark) made the coverage decision; and why didn’t those notices also include specific, written instructions on how request an appeal or exception for longer-term coverage of the drug?
CVS’s communications team sent back this response:
CareFirst is the plan sponsor, and CVS Caremark helps support the administration of the plan’s pharmacy benefit. This CareFirst plan relies on an expert third-party vendor, Medispan, to determine which medications are considered maintenance drugs versus acute. Because Medispan lists potassium citrate as a non-maintenance drug, it is subject to the CareFirst plan’s non-maintenance day supply limit of 30 pills. Members have access to an exceptions process, which is administered directly by CareFirst.
This response didn’t answer my questions about notice wordings. In fact, it suggests that a heretofore undisclosed third party (Medispan) made the decision that limited my prescription. Given CVS’s non-answer, a cynic would suggest the obvious yet unstated reason the notice omitted information about filing an appeal or exceptions request: If people knew about an exceptions process, they might use it.
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