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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