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Foundation Staff
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Posted: Sun Feb 12th, 2006 00:02 |
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Kathy,
Humana approved Benicar 40mg every six hours with a request via phone call or form from my doctor from Jan 04 until Jan 06. They report a change in policy as of Jan.1 for the reason to deny my doctor's request this time.
What was the date that Humana approved your Benicar prescription override?
Best,
Meg
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katydid
Member in Phase 2/3
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Posted: Sun Feb 12th, 2006 00:32 |
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Meg,
My initial "Marshall" appointment wasn't until 1/3/06. I'm certain that it was 1/19/06. I remember because I had just had to ask my sister to buy a weeks worth that had to be paid for in full. I still have the bottle with the date on it 'cause I've been keeping divided Mino in it, by my bedside. Just after she brought it home, my practitioner called and said they had approved 120 per month for one year.
I did make the changes in the letter, and wrote my own, as well, to add to the one faxed from the doc. Hope this helps you. If you need copy of my approval letter, let me know.
Kathy
Last edited on Sun Feb 12th, 2006 00:57 by katydid
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CFS.D's 12/05 25D-7, 1,25D-19,not Quest.Vicodin 10-325 1 PRN.Flexeril 10 mg qday.Westhroid 60 mg.12/27/05 Avoid sun,D Noir's.
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mercuryspice
Member in Phase 3
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Posted: Sun Feb 12th, 2006 01:36 |
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thanks for your help, all of you,
you guys are great!!!!!
lisa
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Lyme 25d 11, 125D44 25D11 Ph1 Sep06 ModPh2Jan07 Ph2Oct 07 Ph3May08 motrin flexeril wellbutrin prozac ativan NoIRs lite exp r/t to school
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Foundation Staff
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Posted: Tue Feb 14th, 2006 02:41 |
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Kathy,
Thanks for the info regarding date of approval of your Benicar by Humana.
I got a letter from Humana's grievance committee today stating the denial of my doctor's request for a Benicar prescription override was an "error". The reason for the denial (which had not been shared with me) was this dose "exceeded the adult maximum dosage guideline that has been established by the Food and Drug Administration."
They wrote: "However, after reviewing your Summary Plan document, your plan does not follow this maximum dosage guideline. We have updated our records and reprocessed your claim."
I don't know if the documentation and letters I sent to this committee helped or if some bean-counter finally read the fine print in the policy. I suspect that my persistence forced the latter since the FDA does not set a maximum dosage. It's important to note that this insurance policy is self-funded and, therefore, the purchaser (my husband's employer) has some leeway in determining what is a covered benefit.
I'm happy the Benicar will continue to be covered but I find this excuse questionable. An insurance corporation should be able to keep track of the terms of a policy they sell. I believe these denials are a tactic to deprive the non-savvy consumer of their rightful benefit. The agent who sold my husband's employer the policy should also have been aware of the terms and I should have been informed in writing of the reason for denial after two years of prior approval.
Where is the congressional investigation for the insurance industry? I'm afraid that this lobby is so powerful that we will never see any real change. Each insurance consumer will need to be very pro-active to be sure they are not denied benefits to which they are entitled.
Best,
Meg
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CarolAHerring
Member in Phase 2/3
| Joined: | Mon Oct 25th, 2004 |
| Location: | Tulsa, Oklahoma USA |
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Posted: Tue Feb 14th, 2006 23:17 |
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| Prescription Solution/ Pacificare pays for Benicare 40mg q6h but they did not want to pay for Mino
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Sarcoidosis/lungs/Heart, Sjogren's syndrome, vertigo, diabetes, 125D46 MP 8/05 oxygen Metoprolol Halcion cyclobenzapine Evoxac Lidoderm Xopenex Ipratropium Bromide 8/12/05 D2517 restart MP
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jillian
Member in Phase 2
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Posted: Tue Feb 14th, 2006 23:24 |
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Meg,
Was the documentation you sent with your appeals different than what is generally recommened in the links Aussie Barb noted above? I'm wondering how much documentation to send with the first appeal letter... I could send inches worth of documentation from what we have here!!!  (Brain fog's kinda heavy right now so if this has been discuessed, just send me in the right direction please.)
thanks and 'til later,
Jillian from North Dakota
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PrimryDX-PulmoSarc79,FMS,CFIDS,etc,disabled93. AvoidD/Noirs Aug02. Oct02: 1,25D=42 NTfrzen; Apr05:25D=10. P1 Oct05-Feb06; ModP2C Feb-Nov06; P2 Nov14-Dec06; ModP2BSS Jan-Mar07; ModP2CBSS Mar07-. Noirs & total light control in house.
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Foundation Staff
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Posted: Wed Feb 15th, 2006 06:04 |
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Jillian,
The first step to get a Benicar prescription override was having my doctor fill out an official request-for-authorization. This was a simple, one-page form. My doc filled it out, sent it in and I obtained a copy from the 'release of information' department at her clinic. I thought the answers could have been improved on so I was actually relieved to learn a few weeks later that Humana had 'lost' the form and needed another. This time, I had them fax the form to me so I could fill it out. Then I took it to my doctor who signed it and faxed it.
I kept the answers simple, hoping that less was more. When I got that official denial, I sent a letter to the Grievance and Appeals committee with the documents (by registered mail) from Barb's recommended list that I thought best fit my particular situation.
I cannot say if these documents did the trick because the reversal of denial letter did not explain their change of mind. It could have been because I asked my insurance agent to call this committee and lodge a complaint. This might have prompted them to actually look at the policy which, being self-funded, may have more leeway than other policies. I also made it clear that I would be contacting the state Insurance Commissioner if needed. The other advantage I had was that this same claim had been accepted many times before.
I would start out simple with brief explanations. And only send documentation for the next step of the appeal process if you are denied.
Best,
Meg
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Reenie
inactive member
| Joined: | Wed Jul 21st, 2004 |
| Location: | Phoenix, Arizona USA |
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Posted: Wed Feb 15th, 2006 20:55 |
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My progress report states what I've been thru trying to get my new mail order to accept my MP Dr's rx and approve it for payment.
I used to work for a very large insurance company and had to deal with underwriters. It's "easy" for them to process claims that "fit" within their box, but very difficult for them to "figure out" how to process something that's not their typical claim.
I know there are lots of various reasons/excuses a pharmacy or insurer may have for denying a claim for a med being rx'd differently than what the manufacturer/Drs typically use/recommend, but I think the reasons are closely linked to the fact that the insurers/pharmacists simply don't know how to "function" outside the box. 
I think for one, if you send in an rx to a mail order pharmacy without any refills, (they usually ask you get a 3 mo supply with 3 refills on your rx mail order) they may "think" you're trying to beat the system by asking for more than you're taking daily which saves the insured additional co-pays. Some Drs will write Rx's that way to save the patients money on expensive meds since there's usually a max co-pay amount. So, it's a good idea to have your Benicar mail order Rx written for a yr's supply.
If you aren't using a mail order pharmacy, you may ask if there's one available since the insurance company saves money on these types of services and some will be more in favor of dispensing routine meds if you use this service. Some insurers insist that you switch to their mail order services if you're on any daily meds.
In addition, my new mail order pharmacy, which I have to use if I want my Benicar Rx paid for by my insurerer, said that my Rx was written with the possiblity of an "overdose" due to the amount it was being Rx'd based on the manufacturer's recommended dosage.
I had to have my MP Dr state in writing he was aware the dosage he was rx'ing me exceeded the manufacterer's recommended dose AND they still insisted on talking to the Dr on the phone to verify what he put in writing, BEFORE the pharmacy would fill my Rx.
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ShrnHml
Member in Phase 2/3
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Posted: Wed Feb 15th, 2006 23:10 |
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Does anyone feel that asking for mail order service would red-flag your scrip and subject it to further scrutiny?
Sharon
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Neuroborreliosis, MP 3/05, 1,25D 62; 3/06 25D<4, ModPh2 12/05, Premarin, Effexor, stopped Benicar 1/07....no longer in study
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jrfoutin
Research Team
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Posted: Wed Feb 15th, 2006 23:46 |
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| Yes. I seem to be making it OK with a month to month script. But when I tried for a 3 month script, red flags went up all over the place. When I said "excuse me, I'll just take one month" then everything appeared to be no big deal. I'd rather do a year at a time, or even 3 months at a time, but if I can do a month at a time and hold a few out each month in a "contigency" file then that is how I will do it (sometimes you just have to increase the Benicar).
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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, 10/08 25D6.9
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Reenie
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Posted: Thu Feb 16th, 2006 20:04 |
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Sharon,
This is the 3rd year and 3rd mail order pharmacy approval I've had, due to my insurer switching pharmacies. I have to use the "one" the insurer selects for them to pay for my Rx.
It might be possible that for a mail order pharmacy may want a little more documentation and may take a little longer in the approval process than a month to month, because they're approving the Rx for a full year at a time, but IMO, it's worth it to get the approval for a WHOLE year rather than have to worry about scrutiny or possible rejection from month to month.
That's just MY personal thought on it. Oh and my insurer won't allow me to get more than 1-3 mos of any med filled that I take regularly from a walk-in pharmacy. I have to mail in my Rx's if I want them to continue coverage on them such as thyroid and mino too. It's how the insurer chooses to save money I suppose and I do too on my co-pays. 
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Foundation Staff
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Posted: Thu Feb 16th, 2006 21:46 |
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Reenie,
My insurer (Humana) uses Walgreen's mailorder service. It isn't Walgreen's that decides if the increased dose of Benicar is approved. Humana does that and then changes my account info so that when I order a med refill, Walgreens is authorized to fill it at that dose.
Best,
Meg
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Reenie
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Posted: Thu Feb 16th, 2006 22:24 |
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Meg,
It sounds like your service is a little different than mine, (at least in this case) or I didn't say it clearly. Let me try to explain in steps, for those following this thread.
1. My insurer decides which mail order pharmacy I must use in order for them to cover the cost of the rx.
2. Once I send the rx to the pharmacy, as in the case with Benicar, the pharmacist was the one that "flagged" my rx order from dispensing it, saying the quantity being ordered on the rx by the Dr exceeded the manufacturer's recommended dosage.
3. Once the pharmacist got enough info from my Dr stating that the Dr was aware he was exceeding the manufacturer's recommended dosage, the pharmacy agreed to dispense the rx as written, although it wasn't one of the pharmacy's "formulary" choices covered by the insurer.
4. If the pharmacy agrees to dispense the rx, the insurer will pay for the Benicar even though it's not formulary. My co-pay is more than it would be if substitution would be permissible. This may be pharmacy/insurer "specific," as in my case and vary with different meds, but my insurer wasn't questioning the Benicar dosage or payment of it; only the pharmacy was. (I called to confirm this)
So, for my situation, the insurer and the pharmacy go hand in hand. In other words, I cannot even elect to pay for the rx out of pocket thru the mail order pharmacy. I asked about this just in case the insurer wouldn't cover the cost of the rx, but that was not the issue as long as the pharmacy agreed to fill it. Last edited on Thu Feb 16th, 2006 23:12 by Reenie
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BARNEY
Moderator
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Posted: Sat Feb 18th, 2006 05:09 |
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Got my prescriptions filled under the Medicare Prescription Drug Plan D (Atena) and I got 136 Benicar (40mg) for $5.00, 45 (50mg) Mino for $2.00 and 100 pain pills for $2.00.
So far, so good. Had a letter of medical necessity at the docs off just in case and the pharmacist did call and confirm the dosage with my doc.
We'll see what next month brings.
HANG IN THERE, WE WILL MAKE IT!!! BARNEY
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64jointsarc77skinsarc80lungsarc81asthma/migranes
95rkidneyremoved(cyst)diabetic/gallbremoved,96
totalhyst(cysts,endom)01fibro,Benicar40/20mg&xtra
as needed,stage5,
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Foundation Staff
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Posted: Sat Feb 18th, 2006 06:08 |
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Reenie,
You make an excellent point that each person's situation is likely to different. Walgreen's is my only mailorder option in order to save a bit of money on the co-pay by ordering a 3 month refill.
Any pharmacy I chose (local or mailorder) will fill the higher dose of Benicar with my doctor's verbal okay, at my expense. However, if I want to take advantage of my Humana insurance benefit, they must approve the dosage override. Without the approval, all they would pay for was 40mg per day.
The decision whether or not to pay for the Benicar is at the discretion of the insurer. Some insurers will only pay for Benicar after another anti-hypertensive has been tried and failed.
Thanks for the info. If you would share the name of your insurer, it might be helpful for other members.
Best,
Meg
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mercuryspice
Member in Phase 3
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Posted: Tue Mar 7th, 2006 14:35 |
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The appeal letter that i sent to the insurance company was denied, I got the letter off the MP website. The insurance says that it's not proven effective or safe at that dosage. I can further appeal, which i definately will. Is there any other evidence I can mail to insurance company to help them change their minds? any help would be great.
thanks
lisa
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Lyme 25d 11, 125D44 25D11 Ph1 Sep06 ModPh2Jan07 Ph2Oct 07 Ph3May08 motrin flexeril wellbutrin prozac ativan NoIRs lite exp r/t to school
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Foundation Staff
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Posted: Tue Mar 7th, 2006 22:13 |
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Lisa,
Ask them to show you in your policy (in writing) where it says that a medication must be proven safe and effective at a particular dose before your doctor's order is followed. Point out that your doctor is responsible for your care and s/he disagrees and s/he is the one licensed to order this medication.
Talk with the insurance agent who sold you or your employer the policy. Ask him/her to go to bat for you. Ask to review the policy with him/her to determine if the insurer really has grounds to deny. They will want to ensure that they are getting their money's worth from this insurer and that their customers are satisfied with the policy they bought.
If you get no satisfaction, ask the insurance company what the process is to appeal the denial. My insurance company has a separate committee that had different requirements than the original committee and different members.
Sending in documentation may be futile in this case since they seem to be using a trumped up excuse to deny a prescription dosage override. IMO, the burden of proof should be on them to show it is unsafe at this dosage because your doctor has the legal right to order it, a lack of studies does not mean a lack of efficacy or safety and this standard is not used for all medications. Many meds are ordered for off-label purposes and at higher than usual doses with no or limited studies and I suspect that they approve those orders because they are more common. This recent get-tough stand against Benicar seems to be merely a cost-cutting measure. I'm hoping that those who complain long and loud to the right people (take it up the line) will get the insurance benefit they are entitled to.
If you know it to be true, you can point out that they have granted this override to others who are insured by them. You can also let them know that you are determined to get your rightful benefit and will be contacting the insurance commissioner of your state if necessary. If your doctor is willing to call or write again, that might carry some weight.
Good luck,
Meg
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mercuryspice
Member in Phase 3
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Posted: Sat Apr 8th, 2006 11:49 |
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My second appeal to united health care part d was denied for benicar at 4 times a day. The next step would be to request a hearing in from of a judge. The denial said that there's no literature saying that benicar is for chronic lyme. Is there anything I can show them? They may reopen the case if I have new materials to show them before I would have to appeal again. I checked a few other companies and they also have quantity limits as well.
Also where can I buy benicar at the cheapest price possible.
thanks
lisa w
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Lyme 25d 11, 125D44 25D11 Ph1 Sep06 ModPh2Jan07 Ph2Oct 07 Ph3May08 motrin flexeril wellbutrin prozac ativan NoIRs lite exp r/t to school
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mercuryspice
Member in Phase 3
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Posted: Wed Apr 12th, 2006 22:38 |
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Is the Aetna still covering your benicar?
what plan do you have with them?
I have united health rx plan and they don't want to pay for it.
I've had several appeals.
i'm medicare part d too.
thanks
lisa
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Lyme 25d 11, 125D44 25D11 Ph1 Sep06 ModPh2Jan07 Ph2Oct 07 Ph3May08 motrin flexeril wellbutrin prozac ativan NoIRs lite exp r/t to school
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ShrnHml
Member in Phase 2/3
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Posted: Sun Apr 23rd, 2006 07:25 |
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My doctor's fax to rebutt denial of Benicar has resulted in another denial. This is the main paragraph from the denial letter:
"We denied this request because we have determined that Benicar for Chronic Fatigue and Immune Defficiency Syndrome is not covered under medicare Part D. This denial is based on the definition of a Part D drug, which excludes from Part D coverage, those drugs which are used for indications that are not appproved by the FDA or supported by information in one of the four medicare designated references."
Do I have bad brainfog, or is this letter unclear? What does Medicare Part D have to do with it? What are the four medicare designated references?
Sharon
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Neuroborreliosis, MP 3/05, 1,25D 62; 3/06 25D<4, ModPh2 12/05, Premarin, Effexor, stopped Benicar 1/07....no longer in study
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