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MaBear
Member in Phase 3
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Posted: Thu Nov 3rd, 2005 19:18 |
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I have insurance coverage with Medco and they have refused to cover Benicar for the MP dosage, in fact I had sent a letter from my doctor stating that it was necessary for the higher dosage and a paragraph from the Am J. of Pharmacology reprint stating that the Benicar was safe at the prescribed dosage but still they would not cover it or dispense it. I spoke to a pharmacist at Medco who stated that Benicar is not approved for"Dr. Marshall's protocol use "and not at such high doses. I then called my doctor's office and asked for a new prescription to get it from another pharmacy and the doctor's office said I may have trouble getrting it from other pharmacies also. Since when did pharmacies practice medicine without a license? Now I am at a loss as to how to get the medication. What can I do? I thought of asking for a lower dosage and just stockpiling it for awhile -- I have had chronic Lyme for 40 years another year won't hurt. Please advise what others are doing?
MaBear--now in Florida
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MIS-DIAG WITH RA IN 1963 AT ONSET OF illness, DIAG WITH LYME IN 2003 BY WESTERN BLOT,BEGAN MINOCY(PULSE)IN 1992 FOR RA AND CONTINUE-TAKE ALSO VARIOUS OTHER ANTIBIOTICS.D-PANEL MAY 31,05 DPANEL D25=32,D125=67STARTED MP FEB 2006.PHASE 3, OCT 10 2006
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Freddie Ash
Member in Phase 3
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Posted: Fri Nov 4th, 2005 14:26 |
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HI MEG & ALL
This is Fred in WV. Well I got my benicar today, but I had to have my doctor call it in to the local Rite Aid store. It was $75.88 today. I am waiting for a letter from Medco stating that they will not fill my mail Rx. Like I said earlyer this was my second try to get it at a lower cost than I should pay by the 30 day supply.
Your friend in sarcoidosis
Freddie
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Freddie: dx-sarc 2/82 lymph; skin, eyes, joints, esophagus, intestines, spleen, heart,lungs-meds digitek, L-thyroxine, nexium, furosemide, nattokinase36mg,eat cinnamon w/meals,25D-7; 125-D43
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DNStog
Advocate
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Posted: Fri Nov 4th, 2005 15:46 |
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MaBear,
I have not had any problems with CVS filling my Benicar prescriptions. The pharmacist did ask me initially to explain why the high dosage AND then wanted to know more about the MP so she could tell her friends. She also said that it wasn't the place of the insurance companies to override what our doctors prescribe. When BCBS (not Medco) initially turned me down, CVS allowed me to buy it at the BCBS contracted amount.  After appealing with a letter from my doctor, BCBS started covering Benicar.
Wishing you well! Donna
Last edited on Fri Nov 4th, 2005 15:48 by DNStog
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Sarcoidosis/skin, joints, lungs, nerves, Raynauld's, uveitis, hypothyroid, sinus, wt. gain, Peradontal disease, GERD-hiatal hernia, breast ca 11/06, 25D7, Synthroid, Wellbutrin, eye vits, melatonin, Milk Thistle, Quercetin, Rx glacier, cover up, low lux h
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Belinda
Research Team
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Posted: Sat Nov 5th, 2005 00:26 |
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Appealing the insurance company's decision
Q: My insurance company has denied coverage for Benicar. No reason was given. I have already sent the letter of medical necessity signed by my LLMD. Any ideas on what I should try next?
A: Meg wrote: Ask your insurance rep what the procedure is for an appeal. My doctor has to call each year and then Benicar is covered at 40mg every six hours as she has ordered.
There is no advantage in mentioning the Marshall Protocol because this is an unknown treatment plan. The emphasis should be on the fact that your doctor is in charge and s/he has determined that you should take Benicar.
Ans ...Your doctor has a license to practice medicine. He doesn't owe the insurance company 'bean counters' any explanation regarding that practice. He just needs to reassure them that he did not make a mistake writing the prescription and that, in his professional opinion, this is the dosage and schedule that this patient needs. Anything else he might say would put him in an unnecessarily defensive position. If they balk, claiming it is unsafe at that dosage, I suggest that he ask them to provide proof of their claim. It is his license that is on the line here; their interest is purely cost containment and he should feel confident that many other doctors are ordering Benicar at this dosage. If he is williing to accept responsibility for the way he practices medicine, they have no right to interfere.
Ans ... I write from the perspective someone who is very lucky to have excellent health insurance but I believe that my opinion applies to all insurance carriers. My doctor has never had to justify to my insurance company why she orders the medications she orders. She has had to verify, annually, that she wants me to take Benicar at higher than usual doses. She has not had to, nor do I think any medical practitioner should have to, justify, to insurance administrators, their reason for prescribing a medication. Medicine is an art and your physician is licensed to practice it as she/he thinks is in your best interest. I hope your doctor will stand up to any insurance official who says otherwise.
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P.Bear R.N.
Research Team
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Posted: Sat Nov 5th, 2005 02:03 |
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| Of interest is that when MaBear spoke to Medco pharmacist, MaBear never mentioned Marshall Protocol or was it mentioned in her letter of medical necessity. The rude pharmacist independently brought up MP. best, P.B.
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MCS, neuroborreliosis, fatigue, tinnitus, neck/facial/shoulder/lumbar pain, Bells palsy, Prostatitis, blurry vision, dizziness, 1,25D=48, MP2/05 MP3, cytomel, D25<5
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Freddie Ash
Member in Phase 3
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Posted: Sat Nov 5th, 2005 10:21 |
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HI ALL
This is Fred in WV. When I first started using the benicar, Medco truned it down by the mail. So I took a Rx to Rite Aid and that pharmacist did question the doseage but said what ever me and my doctor worked out was ok my him.
I am still waiting for the letter from Medco from this week where they turned the Rx down for the mail Rx.
Your friend in sarcoidosis
Freddie
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Freddie: dx-sarc 2/82 lymph; skin, eyes, joints, esophagus, intestines, spleen, heart,lungs-meds digitek, L-thyroxine, nexium, furosemide, nattokinase36mg,eat cinnamon w/meals,25D-7; 125-D43
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Belinda
Research Team
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Posted: Sat Nov 5th, 2005 11:16 |
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Freddie,
I will be surprised if you get anything in writing from Medco. If you do, it will only be because you are persistent with them.
Belinda
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Freddie Ash
Member in Phase 3
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Posted: Sat Nov 5th, 2005 20:39 |
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HI BELINDA
This is Fred in WV. I did receive a recorded phone call when it was denied and they said I would receive a letter in a few days. I did get a form letter last year when it was denied. I still have that letter. I have not reveived the last one as of today.
Your friend in sarcoidosis
Freddie
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Freddie: dx-sarc 2/82 lymph; skin, eyes, joints, esophagus, intestines, spleen, heart,lungs-meds digitek, L-thyroxine, nexium, furosemide, nattokinase36mg,eat cinnamon w/meals,25D-7; 125-D43
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alayne
Member in Phase 2
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Posted: Thu Nov 17th, 2005 04:10 |
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Just thought I'd add myself to the Medco blacklist. They'll only cover 1 tab/day. The amazing thing is that they'll cover my sleep med that's over $700/month, but balk at this. I'd offer to cancel the other med for the Benicar to save them money, but know that wouldn't work. Will have to delay the MP for a while longer now until I can find funds to pay for the tabs. RATS!  Alayne
Just another challenge in a life worth facing and recouping.
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ME/CFS/FM 6/05:25D-34 1,25D-69, 11/07:25D-8 1,25-37, Sick 6-11 mos/yr x20+yrs. NoIRs/Avoid Sun/D/Use Zinc oxide. 11/17/05-Ph1, 5/06-MPh2, 12/06-MPh2#2, 6/07-MPh2#3,1/08-Ph2, 4/08-Ph3, NonMP Meds:Sleep:1-2mgLoraz or OTC q2d/MThistle/Calc&Mag/Lysine
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alayne
Member in Phase 2
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Posted: Sat Nov 19th, 2005 04:17 |
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| Well, I eat my first post. Medco denied me 3xday Benicar on Tuesday, but I was able to pick up 90 last night! The pharmacist was new and didn't know why Medco changed its mind. My doctor wasn't in today, so I couldn't ask there either. Whatever happened, I'm SO GRATEFUL! Will just keep all fingers and toes crossed for the upcoming months! Cheers Alayne
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ME/CFS/FM 6/05:25D-34 1,25D-69, 11/07:25D-8 1,25-37, Sick 6-11 mos/yr x20+yrs. NoIRs/Avoid Sun/D/Use Zinc oxide. 11/17/05-Ph1, 5/06-MPh2, 12/06-MPh2#2, 6/07-MPh2#3,1/08-Ph2, 4/08-Ph3, NonMP Meds:Sleep:1-2mgLoraz or OTC q2d/MThistle/Calc&Mag/Lysine
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Freddie Ash
Member in Phase 3
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Posted: Sat Nov 19th, 2005 11:18 |
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HI BELINDA & ALL
This is Fred in WV. I did get that form letter the other day refusing me the 90 supply of benicar. It was like the last year's letter blaming the doctor for Rxing the doseage for sarcoidosis.
Your friend in sarcoidosis
Freddie
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Freddie: dx-sarc 2/82 lymph; skin, eyes, joints, esophagus, intestines, spleen, heart,lungs-meds digitek, L-thyroxine, nexium, furosemide, nattokinase36mg,eat cinnamon w/meals,25D-7; 125-D43
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Rich
inactive member
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Posted: Sat Nov 19th, 2005 14:09 |
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Fred and Alayne,
I was also refused a 90 day supply but somehow slipped under the radar with a 30 day supply. 40 mg tablets prescribed at 4/day (120 total) for $40 at Costco. The pharmacists don't really seem to care how many you take as long as it is prescribed. The big problem is getting through Medco and not through the pharmacy as Alayne just found out.
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Rich Sarcoidosis 3/03 "remission" 5/04 MP 12/05
12,5-D 50, 25-D 40. Benicar 4X40 mg/day. 100mg mino 3/9/05, Phase 2 3/26 05,25-D22,1-25D 53: 8/15/05 25-D 27,1-25D 45.Phase 3 2/1/06 25-D 15
1-25D,29 Under care of MP literate Dr. Benicar 3X40 mg/day
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alayne
Member in Phase 2
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Posted: Sat Nov 19th, 2005 14:52 |
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Rich, I'm so glad that you finally got Medco to accept! I know you were having a really tough time for quite a while there. (Somehow I missed your early Nov post.)
I purposely asked for a 30 day supply, instead of 90, in order to not raise any more flags than necessary. I was only allowed 30 pills on Tuesday, but got 120 on Thursday. Go figure.
I was wondering if it'd be too risky to ask for 160 pills next month and now see that it probably won't work. You wrote that Medco refuses to cover 160 pills, right? I'd like to have more on hand for emergency purposes, but don't want to rock the Medco boat unnecessarily.
Fred and others, I'm really sorry you've been denied. I don't understand this Medco business at all, except for their wanting to save money. The fact that some people float by and others don't is just plain inexusable. I'm sure their random decisions deny some folks the opportunity to cure themselves because they can't afford the out of pocket costs. I couldn't! IMO, this is a travesty and should be punishable by law.
Good luck all...Alayne
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ME/CFS/FM 6/05:25D-34 1,25D-69, 11/07:25D-8 1,25-37, Sick 6-11 mos/yr x20+yrs. NoIRs/Avoid Sun/D/Use Zinc oxide. 11/17/05-Ph1, 5/06-MPh2, 12/06-MPh2#2, 6/07-MPh2#3,1/08-Ph2, 4/08-Ph3, NonMP Meds:Sleep:1-2mgLoraz or OTC q2d/MThistle/Calc&Mag/Lysine
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clancy 03
inactive member
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Posted: Sat Jan 21st, 2006 11:49 |
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Hi, just checking on the most up to date: Medco issues. Will be starting MP today? We got 84 pills/40mg from Dr's office. but have not tried to fill prescription yet. What is the latest suggestion for getting Medco to pay? The dr has not written scrip yet. We have been going to Costco as well, for other meds. Suggestions. Lynne
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Scott CFS 93/neuro lyme diagnosed 11/05/Noirs 12/05 MP started 1/21/06 Day 28 stopped for 2 days/BeniQ6H/ mino25 2/1/06, Mino 50mg Q48H/motrin tyl for pain/Lunesta 3mg Q24h
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jrfoutin
Member Advocate
| Joined: | Tue Aug 9th, 2005 |
| Location: | Oregon USA |
| Posts: | 3844 |
| Status: |
Offline
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Posted: Sat Jan 21st, 2006 12:40 |
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One Costco pharmacist told me in August '05 they would fill any script from my doctor, and if insurer only paid for part, then they would charge me accordingly but fill the full script (Medco pays part and I pay out of pocket for rest). However, we've found a 3 month fill was problematic but doing one month of 4x a day (120 tabs) is successful. Also, we're coming up on a final refill that will leave a 6 month gap between dosing and next insurance-supported prescription fill.
My good doctor is experienced with both my primary insurer (Medco is assigned to handle prescriptions under their direction) and handling prescription challenges, so we will see how that goes.
Since I am the first Sarcoidosis patient my primary insurer has seen on Benicar, they've told my husband they know Prednisone is a dead end (in more ways than one), they are interested in my progress, and Medco acts as their arm and not the other way around and must do as they direct. Dr. Marshall's recent research and the fall 2005 FDA application for orphan drug status may also prove helpful in further discussion and I fully intend to use them.
I am also unique in that my blood pressure has not yet dropped into "normal" ranges on more Benicar than 1 a day, and my doctor feels that angle has some leverage, too (although Benicar publishes a chart depicting an expected plateau in blood pressure reduction capability and the report could come back to change bp prescription to something more effective).Last edited on Sat Jan 21st, 2006 13:11 by jrfoutin
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Sarcoidosis 125D61, MP10/05 ModP2 12/05 Ph2 6/06 Ph3 10/06, NoIRs limited outings covered, 2/08 25D6.2
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DianeC
Member in Phase 3
| Joined: | Sat Aug 20th, 2005 |
| Location: | New York, USA |
| Posts: | 616 |
| Status: |
Offline
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Posted: Thu Jan 26th, 2006 16:40 |
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Hi,
Medco just denied my mailed in prescription! My doctor will be calling me this afternoon. Please advise as to what I should do? Should my doctor call Dr. Marshall so that she will know how to get this approved?
Thank you!
DianeC
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chronic fatigue/osteoporosis osteoarthritis, 9/05 25-D 40 1,25-D 52 1/06 Benicar 40mg Q6H Mino 28Jan @25mg q48h Mino 12Mar @50mg q72h Mino 15April @75mg q72h Mino 1May 100mg 5/06 Phase 2 D-25 18 10/06 Phase3 D-25 20 5/07 D-25 under 7
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jrfoutin
Member Advocate
| Joined: | Tue Aug 9th, 2005 |
| Location: | Oregon USA |
| Posts: | 3844 |
| Status: |
Offline
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Posted: Thu Jan 26th, 2006 17:27 |
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Do a search for Medco on this site for fuller info sets and how to handle the problem. Here are some other links:
Link to info about Insurance for Benicar.
2004 discussion about legal issues with Medco.
Additional discussion on same topic.
Mostly, be prepared to pay out of pocket at least for an interim period if it occurs.
I've had better results with a month-by-month script/refill at Costco (who said they would fill the whole prescription from the doctor and only charge me for the part the insurance wouldn't cover if worse came to worse).
Also important is a good doctor that will back up his script with a phone call with the pharmacist and willing to take the time to deal with insurance / Medco representatives (letters, phone calls, etc.).
Last edited on Thu Jan 26th, 2006 17:28 by jrfoutin
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Sarcoidosis 125D61, MP10/05 ModP2 12/05 Ph2 6/06 Ph3 10/06, NoIRs limited outings covered, 2/08 25D6.2
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alayne
Member in Phase 2
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Posted: Thu Jan 26th, 2006 17:32 |
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Hi Diane,
I was advised not to request more than 120mg/day from Medco. It seems that 160mg/day may raise too many red flags. I've also heard that obtaining it monthly (retail), instead of through mail order may be more easily accepted.
I'm sure others here will have good advice. Edit: Yes, see Janet's!
Best of luck! Alayne
Last edited on Thu Jan 26th, 2006 17:35 by alayne
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ME/CFS/FM 6/05:25D-34 1,25D-69, 11/07:25D-8 1,25-37, Sick 6-11 mos/yr x20+yrs. NoIRs/Avoid Sun/D/Use Zinc oxide. 11/17/05-Ph1, 5/06-MPh2, 12/06-MPh2#2, 6/07-MPh2#3,1/08-Ph2, 4/08-Ph3, NonMP Meds:Sleep:1-2mgLoraz or OTC q2d/MThistle/Calc&Mag/Lysine
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DianeC
Member in Phase 3
| Joined: | Sat Aug 20th, 2005 |
| Location: | New York, USA |
| Posts: | 616 |
| Status: |
Offline
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Posted: Thu Jan 26th, 2006 17:34 |
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Thank you for replying so quickly! I am reading all the links you have provided.
Thank you!
DianeC
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chronic fatigue/osteoporosis osteoarthritis, 9/05 25-D 40 1,25-D 52 1/06 Benicar 40mg Q6H Mino 28Jan @25mg q48h Mino 12Mar @50mg q72h Mino 15April @75mg q72h Mino 1May 100mg 5/06 Phase 2 D-25 18 10/06 Phase3 D-25 20 5/07 D-25 under 7
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Dr Trevor Marshall
Research Team
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Posted: Thu Jan 26th, 2006 17:49 |
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The situation with Merck/Medco may get worse before it gets better. Three Merck products are effectively given black marks in our recent papers. I cannot control which drugs the science points out as suspect, but I am sure Merck would prefer I wasn't doing any research at all.
In fact, one could construct a hypothesis that the trouble you have all been given during 2005 resulted from our 2004 paper "Putative antibacterial.." One could argue that Merck knew that their ARBs and Statins were on shaky ground, with profound effects on the immune system, way back then, and have been trying to slow our research so we didn't progress to the realizations we have just published.
..Trevor..
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