CVS Caremark denied my son's biologic injection (Humira) saying step therapy requires 'failure on two preferred agents' first. He's already failed both. Has anyone gotten a PBM to actually read the chart notes?

I am at the point where i need to scream into a pillow before every phone call to CVS Caremark. My son is 14, diagnosed with juvenile idiopathic arthritis 18 months ago after about a year of unexplained joint swelling, fatigue, and morning stiffness so bad he could not get dressed for school without help. His pediatric rheumatologist started him on methotrexate as the first line conventional DMARD. He was on it for 7 months. It caused liver enzyme elevation that required us to reduce the dose, and at the reduced dose his disease activity remained moderate to severe. Then she added sulfasalazine as a second conventional agent. He had a severe rash reaction within 5 weeks and had to discontinue.

At this point the rheumatologist said it was time for a biologic and prescribed Humira (adalimumab). She wrote a prior authorization explicitly documenting the methotrexate failure (efficacy plus liver toxicity) and the sulfasalazine adverse reaction. CVS Caremark denied the PA last week with the boilerplate "step therapy criteria not met, member must demonstrate failure or intolerance to two preferred agents prior to authorization of non-preferred agent." We are looking at the exact same denial language that has been on the screen for the last three days. The preferred agents per their formulary are methotrexate and sulfasalazine. Both of which he has failed.

I called Caremark yesterday and spent 47 minutes getting transferred between three different people. The pharmacist on the appeal line said the denial was based on "insufficient documentation of treatment failure" even though the rheumatologist's PA letter explicitly cited dates, doses, lab values, and the rash reaction. When i asked specifically which piece of documentation was missing, she could not tell me. When i asked if anyone had actually opened the attached chart notes, she put me on hold for 11 minutes and came back to say a "clinical reviewer will look at the case again." That was 26 hours ago. Meanwhile my son is in pain, his hands are swelling again because we are tapering off the meds that did not work, and his rheumatologist's office told me they have a backlog of 4 days on peer to peer reviews.

Has anyone gotten a PBM to actually read what was submitted? Is there a magic phrase that makes them route the case to a human who can read a chart note? Should i go straight to the state insurance commissioner or is there a faster lever? The frustrating part is the rheumatologist did everything right. The documentation is bulletproof. The system is processing it like a robot that only sees the formulary code and the patient age.