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Dr Trevor Marshall
Research Team
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Posted: Sat Aug 14th, 2004 01:03 |
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URGENT. Please reply to MEDCO refusing Benicar
I have been delving into reports that Medco Health Solutions is refusing to cover Benicar prescriptions.
It appears possible that Medco is refusing to issue more than 40mg of benicar a day despite a Court order they agreed with 20 States' Attorneys General on April 26th, 2004. A copy of that agreement is covered in press release form at
http://ag.ca.gov/newsalerts/2004/04-049.htm
And the actual judgment is carried at URL
http://ag.ca.gov/newsalerts/2004/04-049.pdf
"THE PEOPLE OF THE STATE OF CALIFORNIA vs MEDCO HEALTH SOLUTIONS, INC., and MERCK-MEDCO MANAGED CARE, L.L.C., FINAL JUDGMENT and PERMANENT INJUNCTION"
I am guessing that Medco is raising the spectre of "Patient safety", because of their responsibilities under this legal settlement, even though we believe that no safety issues exist, nor have any safety concerns been raised by the FDA at these dosing levels.
I need to know how many of you have been told that Medco will not cover your entire Benicar prescription, and whether you know whether
1. "patient safety" was given as a reason, or
2. A questionnaire abour ACE Inhibitors was sent to your Doc, or
3. If you or Doc were offered Cozaar (Losartan) (or any other drug) in lieu of Benicar?
Please email me by clicking my name at the left of this message.
I need just your initial and last name, and info on points 1-3 at this time, no other identification.
Autoimmunity Research Foundation has already written to Medco once, and we will write again Monday, after we find exactly how many folks have been presented with this excuse for not filling their prescriptions. We are pretty certain Medco will eventually reverse this policy, and Medco subscribers will again become covered.
..Trevor..
(Director, Autoimmunity Research Foundation)
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Dr Trevor Marshall
Research Team
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Posted: Sat Aug 14th, 2004 06:01 |
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I forgot to say that Medco looks after claims for Blue Shield, Blue Cross, and a host of other insurers, so you may not know which company refused your claim unless you look carefully at your insurance card. If it says "MERCK" or "MEDCO" then please contact me.
Medco administers prescription benefits for 60 million Americans, according their website:
http://www.medcohealth.com
So some of you almost certainly have been denied by Medco, even if you thgought you were dealing with "Blue Cross", or another insurance company. They subcontract the (cost-cutting) work to Medco.
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nans
inactive member
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Posted: Sat Aug 21st, 2004 20:37 |
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I do not see Merck or Medco on my id card. I Am, however, a member of Blue Shield ppo, and they Did Deny my prescription for Benicar. Once my doctor told them it was not for blood pressure purposes, they said no and refused to speak with or listen to him further. (Forum member "Jelly" reported the exact same experience -- a flat " no" -- Friday, August 6 in response to my posting as to whether anyone had been able to get Benicar under Blue Shield.)
Benicar Is on my formulary.Tho a pre-quthorization is required if there has been no prior ACE incident, and quantity is limited to one 40 mg tab daily, I submit that this attempt to limit its use for blood pressure and its quantity to one 40mg tab daily, is interference with my relationship with my doctor, practicing medicine without a license, and otherwise exceeding its legal power.
I have, further been told on more than one occassion by Blue Shield spokesmen that how a drug is used (i.e. on or off-label) is irrelevant to their considerations. Either a drug is on formulary and is covered, or it is not.
Unless I hear from you to the contrary, I will be contacting the Blue Shield pharmacy division this coming Monday to discuss the matter further with them -- including pointing out that they are acting in violation of the law in denying payment for the medication.
____________________
CFS fibro anx dep ?lyme multiple symptoms/ TEST 25=13 1,25=57 4.3:1/ Beni40mg 4-6q 9/17/04 / Noir 1/12/05 Phase II 3/4/05
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chill
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Posted: Sat Aug 21st, 2004 23:34 |
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| I called my Blue Cross customer service and they said that I could get as much as 100 mg. per day, but is that enough for the protocal? It is Medcohealth by the way.
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Cindy Hill
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Meg Mangin R.N.
Research Team (on leave)
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Posted: Sun Aug 22nd, 2004 13:54 |
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Nans,
I agree with everything you said. Keep putting pressure on them until you get your full insurance benefit. Only a doctor is allowed to determine what a med is used for and how much is ordered. Prescribing off-label is a common practice and the fact that Benicar is on their formulary is the main thing. Did you ask your doctor to send the letter of medical necessity? It's in the What is the Marshall Protocol forum.
Chill,
100mg/day is not enough but it's good sign that they were willing to go up. With a little pressure from you and your doctor, they should agree to pay for what the doctor orders. The recommended MP dosing is 40mg every six hours.
Good luck to both of you,
Meg
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Nothing contained in this site is or should be considered, or used as a substitute for, medical advice, diagnosis or treatment by your physician.
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nans
inactive member
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Posted: Mon Aug 23rd, 2004 19:04 |
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Just to clarify, Blue Shield rejected my claim altogether. They refused to cover Any amount of Benicar -- not even one 40 mil tablet per day -- since it was not for blood pressure.
I had sent the letter of necessity to my doctor, and armed him with numerous other pertinent documents from the Forum relating to the scientific basis, success records, FDA reports and other materials on the subject.
He said, however, that Blue Shield was unwilling to discuss any of it. As soon as he said tthe pills were not to treat blood pressure, he was told that they would not pay for any of the medication, and the conversation was terminated.
The below chart, from the Blue Shield web site at mylifepath.com, shows that Benicar is indeed on the Blue Shield PPO formulary. Blue Shield appears to base itsdenial on the Restrictions/Notes that follow -- interpreting the provision to limit appproval to use as an ACE inhibitor for lowering blood pressure only.
Drug Name
Brand or Generic
Generic Available?
Formulary Drug?
Restrictions/Notes
Class
Benicar
Brand
Not Available
Search for generic alternatives in class
Brand: Yes
Prior Authorization required if no previous therapy with an ACE inhibitor (quantity limit of 1 per day)
Hypotensives,angiotensin receptor antagonist
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CFS fibro anx dep ?lyme multiple symptoms/ TEST 25=13 1,25=57 4.3:1/ Beni40mg 4-6q 9/17/04 / Noir 1/12/05 Phase II 3/4/05
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nans
inactive member
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Posted: Mon Aug 23rd, 2004 19:16 |
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Sorry. The Formulary chart did not transmit properly. It should read:
Drug Name: Benicar
Brand or Generic: Brand
Generic Available: No
Formulary Drug: Brand, Yes
Restrictions/Notes: Prior Authorization required if no previous therapy with an ACE inhibitor (quantity limit of 1 per day)
____________________
CFS fibro anx dep ?lyme multiple symptoms/ TEST 25=13 1,25=57 4.3:1/ Beni40mg 4-6q 9/17/04 / Noir 1/12/05 Phase II 3/4/05
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Jelly
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Posted: Fri Aug 27th, 2004 13:29 |
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| I was refused by Blue Shield. Not only would they not cover the 40 mgs. every 6hr, but they would not cover any part of it. They just refused even a typical dose for high BP and offered no alternative which usually they do.
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pennyhoule
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Posted: Mon Aug 30th, 2004 13:08 |
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Jelly,
My insurance also refuses to pay for a partial prescription (on a script written for 3 or 4 a day). But they can't refuse if my doc writes a seperate prescription for 1x day. That's what he did for me. Wrote one for 1xdaily, then another for 3xdaily, which I pay for myself. It's a pain, and half the time I have to argue with the pharmacist about why I have 2 prescripts for the same drug, but it works and they eventually get it (I have to admit that it's complicated because they have about 4 or 5 different prescripts from my doc for Benicar, because at different times we thought my insurance would pay for 2xday, in the beginning I had one for 3x day, etc).
Actually, I'm seeing doc today, and I"m going to ask him to write me a completely seperate script for 4x a day,which I'm going to get filled at Costco, out of pocket. Then, I'll go to Sav On, and get the 1xday filled which is a co-pay situation. That way, I can either have some extra on hand for bad days, OR, I can just be a little slow on the refill at Costco and will at least save a little money. It's going to be a whole lot easier than arguing with the pharmacist every time. :-)
I'm still trying to get a letter of medical necessity to the right department at my insurance company, to see if they'll cover it. Although, with everything I've been reading, it's not sounding promising. So far, they claim they haven't even received my doc's letters. And I know they were sent, because I sent them myself. :-(
Insurance companies are not here to help us, that's one thing I've learned throughout my whole health ordeal. they're here to make it as impossible as they can for us to get financial reimbursement for our treatments. In reality, the stress I've had to deal with because of my insurance company has done more to contribute to my lack of health, than to getting better.
penny
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Amy
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Posted: Tue Aug 31st, 2004 12:33 |
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Hi.
I have Coventry Healthcare of Iowa, and they will only cover 1 pill of Benicar per day. The pharmacy gets very confused when I need a refill, too.
Amy
____________________
Lyme/CFS/FMS/Endocrine disorders/12 years
Doctor did NOT run pre-MP tests. Benicar 120mg.
Started the MP on June 21, '04
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pennyhoule
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Posted: Mon Sep 6th, 2004 22:26 |
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Went to pharmacy today and my previously very good insurance won't cover the zithromax now. They used to pay for everything, including zyvox at $60 per pill. Anyone else with either United Health Care or Medco not able to get Zithro covered? (Medco administers the UHC pharmacy program - which I don't use) It's $333 out of pocket for the zithro.
I'm getting worried that Medco may be behind this, making this determination that Zithro is not a covered drug. I'm also concerned about my doc. The last thing I want is some big insurance company harassing him for prescribing the MP.
Was anything ever resolved with Medco and the Benicar issue or could this be the reason I'm now not able to get zithromax either. Because they know I'm on the MP?
penny
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Jelly
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Posted: Mon Sep 6th, 2004 22:42 |
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Hi Penny
Sorry I just saw this today when you posted your last post. We tried that route too, they refused both. Maybe it was because we tried the larger first, then the second smaller quantitiy.
Good idea to go to Costco. Was it a lot less expensive?
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pennyhoule
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Posted: Sat Sep 11th, 2004 17:45 |
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I think perhaps the zith wasn't covered because the way my doc wrote the script. I have to follow that up.
Costco is around $160 for 120 tablets. Pretty good price. And the people that work there are SO much nicer than any of my other pharmacies. Seriously, those people cause me so much stress it's unbelievable.
Just heard on the news yesterday that a complaint has been filed against Albertson's/SavOn for selling patient information. Serves them right, they are definitely not pro-patient and it wouldn't surprise me in the least. Couple years back it was Rite-Aid for selling out of date drugs. Sheesh. The people at my local costco are very refreshing.
penny
p.s. I just got the weirdest letter from Medco, asking me to verify two antibiotics that I took in 2003. Wonder what that's about? (at least I know for sure now that Medco IS administering my pharmaceuticals - it was hard to tell before).
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Reenie
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Posted: Mon Sep 13th, 2004 16:22 |
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"Anyone else with either United Health Care or Medco..."
Penny,
I have UHC for my prescriptions and my plan is administered by Eckherd Health Services. They require me to mail in to Express Pharmacy for any meds I routinely take. I wonder if this mail in service is available to you under your UHC plan. This may be different than your plan but worth checking into.
BTW, if I go to a local pharmacy more than a couple of times, UHC will refuse coverage on for my scripts, since they require I mail them in to the mail order pharmacy. It's a very convenient and cost effective service.
Last edited on Mon Sep 13th, 2004 16:23 by Reenie
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pennyhoule
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Posted: Tue Sep 14th, 2004 16:47 |
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Hmmm, I must have a different plan than you do. I know I have some kind of mail order option that can "save me money", but they make it all so confusing, and with my brain fog and fatigue I never really figured it out. But I've never been denied coverage on ANY drugs until very recently.
I do know that they aren't happy with me, because my treatment so far has been in the hundreds of thousands of dollars, and they started getting really resistant when I was on i.v.s, assigning me this horrible personal care person at UHC who had a completely faked "caring" voice who was really just trying to trip me up so she could deny benefits. I was so sick at the time, I just couldn't deal with her at all.
penny
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pennyhoule
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Posted: Thu Sep 16th, 2004 14:36 |
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Two interesting events regarding prescription coverage. My good friend also has UHC (pharmacy administered by Medco) and she is getting full coverage on her Benicar. So apparently there's something we're missing here.
My new Benicar pharmacy, Costco (they are so much better than SavOn), told me yesterday that they could get some info from doc and override the insurance denial on the Benicar, so they are trying that now. We'll see what happens. It could simply be that pharmacies vary on how much effort they'll make for the patient. I have never found Sav On or Rite Aid to be patient advocates.
By the way, my regular pharmacy (Sav On) called doc on my zithromax denial, and that was somehow reversed so I do have Zithromax covered now, which UHC/Medco was refusing last week.
penny
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nans
inactive member
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Posted: Sat Sep 18th, 2004 22:45 |
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DO ANY CLINICAL TRIALS EXIST RE: BENICAR USE FOR CHRONIC INFLAMMATION?
Denial History to date:
- Rx denied at pharmacy level
- Doc said when he called Blue Shield of California (BSC) pharmacy services for authorization, was told lowering bp is the only use for which coverage is approved.
- In follow-up call, BSC told me it had no written record of that contact. And sent 3-item questionnaire for doc as to: diagnosis; dose and direction; other medications tried, when, and outcome?
- Doc sent letter of medical necessity in reply. Said I was under his care for chronic systemic inflammation and Lyme disease, and answering their other questions.*
- Letter from BSC Medical Director for Medical Policy, Chairman Pharmacy Therapeutics Committee again denied authorization, Focusing on Use, its rationale, ‘Clinical information from my provider does not meet the coverage criteria established by the BSC committee. FDA has not approved this medication for use in your condition, and BSC does not have peer-reviewed medical literature from at least two controlled clinical trials to support its use for this condition at this time.’ It closes urging me to discuss alternate drug therapy with my doc - ignoring that there is none.
DO SUCH TRIALS EXIST? IF SO, WHAT ARE THEIR EXACT TITLES AND WHERE CAN THEY BE FOUND?
Since 'my condition' is listed as chronic systemic inflammation, the trials can be for ANY chronic systemic inflammation or even any single-site inflammation as long as they have the required elements.
Absent that, what documentation would be best to show use for chronic inflammation? Is there, for example, something stronger than the New England Journal Medicine (nov 2003) inference that Benicar Might be used for MI?
Finally, what is my next step in this case? Would it be better to have Dr. Marshall speak to the Medical Director of BSC policy? Should I write my own response stating All the reasons I believe the denial is wrong? Are Medco talks such I should wait as long as I’m allowed?….I am open to suggestions as to how to best handle this. Thanks Nans
*The LMN continues: "In light of her failure to respond adequately to numerous prior medical interventions, including recent use of various and multiple antibiotics, I have prescribed Benicar, an Angiotensin II Receptor Blocker, at 40 mg every four to 8 hours in order to block the TH1 inflammatory cascade and enable the immune system to return to normal function.
Neither generic nor other medications in this class will work for this purpose. Brand Benicar is the only Angiotensin II Receptor Blocker known to stop this aspect of the inflammatory response. It also potentiates antibiotics to treat any remaining bacterial infections more effectively at low doses.
This inflammatory blockage works only if an adequate blood level of Benicar is maintained by dosing every four to eight hours as required. This medication does not work effectively for this purpose at lower doses. Patients with inflammatory disease have many additional Angiotensin II receptors in their inflamed tissues. These receptors need to be substantially blocked to provide an adequate anti-inflammatory effect. The 4-8 hour individualized dosing (in full accord with labeling and FDA mandate, and within FDA guidelines) is critical for the drug to achieve its desired effect.”
____________________
CFS fibro anx dep ?lyme multiple symptoms/ TEST 25=13 1,25=57 4.3:1/ Beni40mg 4-6q 9/17/04 / Noir 1/12/05 Phase II 3/4/05
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Dr Trevor Marshall
Research Team
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Posted: Mon Sep 20th, 2004 05:17 |
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Nans,
The reason there will never be any controlled clinical trials is that the FDA safety file itself contains safety data at doses to 320mg of benicar, so there is no need to do controlled studies to prove the safety. Several longer term safety studies have already been conducted to 80mg.
The FDA safety file says nothing about lack of safety. What are these pharmacists smoking? Medco have just settled a lawsuit brought by the States' Attorneys General and now seem headed towards a class action suit as well. Crazyness (IMO).
Here is what I wrote to Medco summarizing the FDA study.
"How can you suggest to patients and their physicians that dosing of Olmesartan Medoxomil in excess of 40mg qd is unsafe? How can you tell them that there are no studies at higher dosage? You never raised this issue with me. If you had done so I would have been able to refer you to the FDA CDER document "NDA 21-286, Medical Review of Efficacy and Safety, Benicar", and the studies within it, namely study protocols 866-101, 866-102, SE866/01, SE866/0, SE866-04, 866-09/EU, 866-06/EU and 866-204/US, studies conducted with doses up to 320 mg of Olmesartan Medoxomil."
The first 52 pages of the FDA safety file is available online at http://www.fda.gov/cder/foi/nda/2002/21-286_Benicar_medr_P1.pdf
and the second 52 pages is at
http://www.fda.gov/cder/foi/nda/2002/21-286_Benicar_medr_P2.pdf
..Trevor..
ps: as for the issue of efficacy, the issue of off-label prescription for diseases where no FDA-approved drug is available is solely at the discretion of your physician. He could always seek a second opinion to back up his judgement on the efficacy issue, if the Medco pharmacist insists on that.
pps: Please let us know what happens
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sujay
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Posted: Wed Sep 22nd, 2004 15:53 |
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The hang up seems to be on efficacy rather than safety per se. Anyone with headaches as part of their symptom mix might ask their physician if migraine might be an appropriate diagnosis to run through.
I agree that the insurane companies are wrong to deny payment for these particular meds, but, as a practical matter, we need a simple solution if we can find one. I'm going to give this a try (where medically appropriate), and I'll be interested to hear if anyone else has any success with this approach.
Sujay
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TX Lyme Mom
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Posted: Wed Sep 22nd, 2004 18:02 |
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Sujay,
If efficacy is the issue, rather than safety, then why not show them Trevor's most recent publication which was accepted in a peer-reviewed journal and indexed on PubMed?
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15246025
The full text of this article can be accessed via the link below. Sorry, but I haven't learned how to use "tiny-url" yet in order to shrink those really long URLs which don't post very well, but I trust you won't have too much trouble finding it this way instead.
http://trevormarshall.com/papers.htm
PS - If they insist on two, instead of only one, reference(s), then take note that Trevor has another one pending "in press", but I sincerely hope you don't have to wait for its official appearance in order to prove your point to the insurance company. (Not all of Trevor's other papers have been indexed on PubMed so the insurance company might try to argue that they don't count.)
PPS - I'm editing now to say that I realize how naive I was to post what I did because Medco is linked to Merck, and Merck manufactures its own ARB, so both companies are going to have a vested interest in not approving any drug from a Japanese company which competes with Merck's own ARB.
Last edited on Wed Sep 22nd, 2004 18:23 by TX Lyme Mom
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Care-Giver & Lyme/CFIDS/MCS Support Group Leader; healthy (not a patient) so no D-level data for me
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