Insurance Denying Formulary Medication
I have a formulary question. I am insured for prescriptions with Caremark. I’ve really been getting the runaround. I am trying to get prior authorization for a narcolepsy medication. The medication is covered in the formulary. First I had a step therapy requirement. I have completed that and the medications they wanted me to try were ineffective. Then Caremark tried to say I needed to have chart notes demonstrating a beneficial response to the medication I am trying to get approval for. A medication I have not tried. Then they told me I am probably allergic to the medication with no basis for this. Then they told me I needed to have proof that the step therapy didn’t work. It’s narcolepsy there’s not exactly a readily available test to prove that. Then they just said the prior authorization was missing information and refused to say what the missing information was. All the while my doctor was providing answers to all of these ridiculous statements in new prior authorizations. He finally submitted an appeal and I am waiting for the 30 day mark so I can receive the decision.
The medication is quite expensive, $13,000 a month according to my insurance website. As I said the medication is in the formulary. Is Caremark, or any insurance I suppose, allowed to deny a formulary medication when all requirements for that medication have been met? The requirements are only to have narcolepsy as defined by a sleep study and then step therapy with 4 medications. I am concerned that the only reason this is dragging out is cost and I worry they will keep denying to pay for it.
