OptumRx is not real forthcoming with their process. After they deny the two pre-auths, you can immediately appeal and ask it be submitted for review.
CalPers members get two instead of one Pre-auth review. The CalPers Board thought it was protecting its members by asking for a review x2 to assist members in timely receipt of their medicine. OptumRx figured no one was going to actually vet their process, and either charged more or wrote razzle dazzle language giving the impression they actually had a viable process that helps the CalPers members get timely meds. It probably helped in the awarding of the contract In reality, the same office with the same (very nice) people review the doctors script submission both times its submitted.
The second time its submitted, its reviewed by a "specialist". Near as I could tell that does mean credentialed expertise (nurse, doctor, PA, NP ) but is a person who processes the claims specific to that genre of need. There is no one there with the credentials to review additional information to substantiate the medicine or the amount... So they will ask for it and you can submit it for the second review, and it will change nothing in the outcome.
So, if they said no the first time, they will say no the second time unless its a typo, or you prescribe consistent with their newly revised formulary which is 2nd world, financially driven absent contemporary medical research (at least in my specific case). After that second denial, you can initiate an appeal for review. That different office is likewise primarily staffed with really nice people who are not credentialed to make medical decisions. However it seems they have access to individuals who are.
By their newly revised definition of "peer", your doctor can talk to a pharmacist as a peer, in determining medication and dose suitability. Not sure yet how that plays out. If you are not satisfied with that decision, from the appeals review, you can contact the State of CA and file with them. I'll check back for your response and leave that info in here, if this is still a live thread or you still have concerns.
Also, it will really help when you get a denial to write to the address provided in that letter and clearly state the request for those research studies and/or information with citation (author, title etc, FDA # and info, and so on). upon which the formulary is based. Keep this documentation for any Class Action lawsuit emerging from this. Though hopefully CalPers is given the chance to make this right, and they deserve (imo) notice and opportunity to intervene.
Many companies are not used to California's demand for accountability and Agencies that support the demand for accountability. This company is based in Arkansas... Maybe its time we help them see what makes public servants in CA such great people..... the CalPers Board has a lot of variables to juggle in meeting the demands of taking care of its people.
I doubt any of this is okay with them. Somehow they have to get word this is going on, as by my account, its erupting all over the place, and it only getting worse. No Agency, Board or Director is going to support some company coming in and making huge profit off the health and well-being of its members as some kind of easy picking cash cow. We're the second largest behind US Gov something in the purchase of health care.
But those vendors have to earn our business and don't get to reap excessive profit because no one can figure out how to get their meds. Don't give up, don't give in, we're CalPers members and we need to look out for each other in taking care of each other so we continue to thrive.
Product or Service Mentioned: Optumrx Prescription Refill.
Reason of review: Policy Based Denial of Medication.
Preferred solution: Hire credentialed people with authority to deliver services the unit presents as offering (and can't/doesn't). For starters..... 2) pre-auth and appeal process horribly vague and not well defined. CalPers members are sticklers for accountibility. .
I liked: Some staff in pa very helpful, Staff did what they could to help.
I didn't like: Changed formulary after 49 billion dollar contract awarded, Catchy slogans like evidence based hides profit from denials, Demands physician treat their paperwork and not patient.