Appealing a PBM adverse determination to have a drug covered for a condition not included in the plan criteria

If I understand correctly, they are supposed to consider “medical necessity” in the appeals process after a prior authorization has been denied, and not just the conditions that are listed under the plan criteria. The condition that I suffer from is not included in my plan’s criteria for this drug, but alternative treatment has failed and there are some clinical trials to support this usage, although it is not approved for this indication by the FDA. My physician has stated that filing an appeal would be useless as they would only be considering the plan’s criteria. My PBM is CVS/Caremark and if the internal appeal is denied I think the external appeal would be to the California Department of Managed Health Care, although it might be a different entity due to it being an employer-provided self-insured group health insurance policy. Is my physician correct, or should I file an appeal? Would appealing even be feasible without my physician agreeing to do so?

submitted by /u/Biochem-anon3
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If I understand correctly, they are supposed to consider “medical necessity” in the appeals process after a prior authorization has been denied, and not just the conditions that are listed under the plan criteria. The condition that I suffer from is not included in my plan’s criteria for this drug, but alternative treatment has failed and there are some clinical trials to support this usage, although it is not approved for this indication by the FDA. My physician has stated that filing an appeal would be useless as they would only be considering the plan’s criteria. My PBM is CVS/Caremark and if the internal appeal is denied I think the external appeal would be to the California Department of Managed Health Care, although it might be a different entity due to it being an employer-provided self-insured group health insurance policy. Is my physician correct, or should I file an appeal? Would appealing even be feasible without my physician agreeing to do so?
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