Waiting for the external review

Caremark refused to cover Zep and treated the PA from the doctor as if I were a new patient requesting it, when I've actually been on it since 11/1/2024. According to their own plan info for exceptions based on continuity of care, I met the criteria for an exception for both management of weight loss (must have been on it for X number of months & lost & maintained a loss of 5% of starting body weight - I've lost almost 40%) and for sleep apnea (must have moderate to severe OSA & had a reduction in symptoms - according to my recent sleep study & my doctor, I no longer have OSA so definitely a reduction in symptoms! ). But they treated it like a brand new PA for a new patient, deemed it not medically necessary bc there is a formulary option (Wegovy) and I must try that first & fail before I would be considered for an exception. The second adverse letter let me know that a medical professional specializing in rheumatology reviewed the request & that was their conclusion.

I'm sure they assumed I would give up. In MN, they were required by law to assume me information about how to request an external review & they sent me out of date information, including that I needed to pay a $25 fee to even request the external review. I ended up calling the MN Dept of Commerce to ask if I should mail the whole application form & the $25 check in together or just the $25 check & send the application in by fax or email - turns out, there's a new form online & there was no longer a fee but Caremark sent me the old forms. Can't help but wonder if that was intentional in the hopes that the fee would be a deterrent but I'm likely just being cynical.

Anyway, I put together a 45 page packet to submit along with my external review application because if I'm going to get denied again, I want a really solid record for any upper level appeal after this. I needed to fill out the external review application & send my denial letter, so I had those separate from my packet. I made sure to include the additional info Caremark sent me with the criteria for exceptions, highlighting the two under continuity of care for weight management & OSA.

My packet included:

1. a two page personal statement explaining the information I had included, that I had lost 40% of my body weight, my OSA was in remission, my blood pressure was in the normal range instead of 140s/110s, my chronic knee pain was gone, and laying out why I met the criteria for an exception for continuity of care for both weight & OSA;

2. A letter from my primary care physician with her medical opinion that I should remain on Zepbound for medical reasons including lowered blood pressure & lower BMI;

3. A letter from my sleep specialist specifically saying the use of Zepbound has been the primary reason I've no longer got OSA & that studies show cessation of Zepbound often leads to regaining the weight, which would mean I would again have OSA, and urging them to reconsider the decision to deny coverage based on my medical needs;

4. Multiple pages of medical records documenting my starting weight, my weight at various times over the last 17 months, clinical notes that I was tolerating the medication well, blood pressure readings over time, notes about taking me off my blood pressure medications bc I no longer needed them, notes from the sleep specialist about my prior OSA diagnosis & my most recent sleep study results, & notes that said I no longer need to use a CPAP;

5. Copies from both the retail pharmacy showing continuous filling of the medication from 11/1/2024, as well as receipts starting in 2026 from Lily Direct showing I've been self paying since coverage dropped (to foreclose them from saying I've not been taking it since I lost coverage & I had not gained anything back AND bc I am also asking them to order Caremark to reimburse me for the last few months of out of pocket);

6. Screenshots from my exercise app that I've been using since Jan 2025, which tracks how many minutes I work out, so I could show that I had made "lifestyle modifications unison