GROUP HEALTH, CAREMARK CVS, AND MOI

What may have started out as a simple communication problem will now turn into a major storm.  We shall call her Hurricane Mollie.

My amprya prescription is all gone on Tuesday, September 7th.  Ampyra is a new drug approved by the FDA for persons with MS who have trouble walking.  Ampyra helps some of us, including me.  So after working tirelessly with Caremark, Group Health and my neurologist, and hitting a lot of brick walls, I finally got the rx approved for benefits last month.  I've been taking ampyra for almost 4 weeks now and am actually noticing some improvement.  And, just yesterday, my hair stylist made the observation that my walking had improved; and Andrea didn't even know I'd started the drug!

A brief recap:  Ampyra is a new drug approved by the FDA and is on the formulary list with my Health Benefits provider, Group Health.  Group Health has contracted to provide  formulary mail order prescriptions with Caremark CVS, a third party.  I had to jump through hoops and hold hands at Group Health and Caremark to get the prescription filled in the first place, but my neurologist did write the script for the drug, with permission for three refills.  And, after a lot of negotiating with both parties and my neurologist, I finally was able to fill the prescription.  But it wasn't easy, and took the patience of Job to lead both corporate professionals to do their jobs.

(note to reader:  a formulary drug is a new drug recently approved by the FDA that is really, really expensive)

Mistake #1

So, it's 3 1/2 weeks later and I need my refill.  Ampyra isn't the kind of drug you stop cold turkey, I guess you have to taper off.  How, I don't know, not being a "medical professional."  I called Caremark to find out the status of my refill request and was told that it was in a holding pattern until Group Health gave the go ahead to refill.  They told me to contact Group Health.

Mistake #2

Today is September 2, 2010, and there are only 3 days left to get the rx by mail (for those on another planet, like Group Health and Caremark CVS, the USPS doesn't deliver on Sunday or Labor Day).  I asked if someone from Caremark CVS had contacted Group Health to let them know that the rx was running out, and they said "No, it was Group Health's responsibility to contact us once we asked for authorization to refill."  I asked the person on the other end of the line if they weren't concerned with the medical implications that would ensue if they didn't contact me to tell me of the delay, and they said "No, they have to contact us."

Mistake #3

So I contacted Group Health and asked what the problem was.  After being transferred to several extensions, I finally ended up in the Medicaid department (I do have Medicare, but don't have prescription drug coverage since I have it with Group Health . . .) and I was told that Caremark CVS needed to notify them of the problem. When I told her that Caremark CVS told me that they HAD contacted them and had heard nothing, the "medical professional" on the other end of the line said "We have no record of that."

Mistake #4

So I asked the "medical professional" on the other end of the line what to do.  She told me to call Caremark CVS and explain the problem and that Caremark would have to make the phone call.  I took the phone number and called Caremark CVS.

Mistake #5

Caremark CVS told me that they had needed the authorization for payment (a reasonable response, considering the expense of the prescription), but would not ask AGAIN for authorization to fill (not reasonable IMHO).  I was told to call Group Health to expedite the authorization for payment.

(note to self:  why do none of the "medical professionals" at Group Health and Caremark CVS know how to pick up a phone and push buttons?  They sure knew how to push mine!)

Mistake #6

So I called Group Health and was then told that they had contacted my neurologist for a medical explanation as to why I needed this formulary drug.  I reminded them that she'd contacted them last month, when the prescription was initially written, with medical justification for a formulary drug.  Nothing had changed, and at that time, she'd authorized 3 refills.

That wasn't good enough.  My neurologist, she said, had to do this with every refill.  My heart sank, since I knew my neurologist was out of town until next week, and I'd have to bring the neurologist on call up to speed.  Sigh.

Well, I'm only human, so I finally asked the Group Health "medical professional" what they advised since my neurologist was out of town, I had no instructions on how to taper off the Ampyra, it would run out Tuesday, and I was ill prepared, as a patient and Group Health member, to figure out what to do.

Mistake #7

She told me to call Caremark CVS.

Are any of you dizzy yet?  Is this how "medical professionals act?"  When is something  a miscommunication, when is it a mistake, when is it malpractice, and when is it negligent homicide?

So I finally called Caremark CVS and spoke with Katrina, the only rational person at either organization.    Katrina transferred me to her supervisor who understood the problem and told me he would fix it.

Well, supposedly he has; I can expect to take delivery of my refill on Saturday, they are sending it overnight mail tomorrow.  But I'm not believing it until the refill is in my hand.

Why can't "medical professionals" handle problems without involving an ill suffering patient in the equation?  Why couldn't any of the Caremark folk transfer my call as Katrina finally did, rather than telling me to contact Group Health?  Why didn't Group Health contact their contractor, and find out why they were having problems filling my prescription?  Isn't that how it works in the rest of the world?

"Health Care professional" is a euphemism for anything but health. care. professional.  I just hope I can get through the MS experience without one of these professionals killing me with their negligence, laziness and inability to care about the patient.

This situation was finally handled by me, not by the "medical professional" community who rake in millions of dollars just to tell the sick patient that health care management is in the hands of idiots who can't (or won't) dial phones.

Addendum:

My ampyra arrived this morning via overnight mail.  Now, I only need to know that no other innocent patient is endangered by this horrible "pass the buck" attitude in the health care industry!