The Marshall Protocol Study Site > ABOUT THE MARSHALL PROTOCOL > General Information and FAQs > Medicare Drug Plans
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The Marshall Protocol Study Site > ABOUT THE MARSHALL PROTOCOL > General Information and FAQs > Medicare Drug Plans |
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tom Member in Phase 3 
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Planning on applying for the new Medicare Prescription program. If anyone has any insite as to the best way to maximize benefits for Benicar coverage I would greatly appreciate it. Feel free to private message me. Thank you tom |
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Foundation Staff . 
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Tom, As I understand the new Medicare plan D for prescription coverage, you need to choose an insurer whose formulary lists the most medications that you take or the most expensive ones. I don't know if it's possible to find out which insurers, if any, will be receptive to a doctor's request for a 'prescription override' to cover the cost of the MP's increased Benicar dosage requirement. Best, Meg |
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jillian Member in Phase 2 
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Tom, If you meet the financial guidelines for Medicare to cover the cost of your premium, you would need to do this somewhat differently. I'm not eligible, and the MP meds are the only ones I'm taking. This is what I'm doing: I went to medicare.gov site; clicked the Formulary Finder link; entered my state and Benicar in the drug finder blank. They then listed the plans in my state that cover Benicar. From this list of plans, and this part is critical in my opinion, click each of the plans and see if they do not LIMIT QUANTITIES and do not have STEP THERAPY. Of the 32 plans listed for me that cover Benicar, only four cover 'unlimited' Benicar (and are not MAPD, managed care type of plans that I'm not interested in). For me the premiums range from $38 to $100/month. I'm in the process of calling each of these insurance companies to be assured they do cover unlimited Benicar, and what the cost of the Beni will be. I expect they'll balk once the prescription comes through though, so I'm going to speak to my doc about it, and will be prepared with extra Benicar in case the appeal takes a few weeks for the doc to iron out. Frankly I'm not too optimistic they'll cover 120 tabs of Beni for $60 as I've been told they will, so I do expect some issues to be made about it... If, in the end they will not cover unlimited Beni, I can drop out of their program. (All I've lost in that case is hours of precious time and way too much mental energy! I suspect in the end it'll all be a waste of time and I'll end up paying full price and not being able to afford that and the premiums on the insurance...) Also, FYI, only the bigger chain pharmacies have agreements with these couple of companies, none of the local pharmacies do, so I'll need to change pharmacies. That's not an issue for me, but could be for some people. Needless to say, I'm doing this during my best non-Herxing moments when my brain is somewhat clearer  'til later, Jillian from North Dakota Last edited on Wed Nov 30th, 2005 03:48 by jillian |
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Foundation Staff .
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Jillian, That's valuable information. You have provided us with some key questions to ask. For those who don't know, STEP THERAPY is when you must try a cheaper medication in the same category first and find it ineffective before the insurer will pay for the higher-priced medication. This is a common cost-saving practice and Benicar is not the cheapest anti-hypertensive so it would be denied on that basis. I have found our local Office on Aging to be a great help to those who are confused by this new program. Anyone who is having trouble figuring out what they should do regarding Medicare plan D, should contact their local aging or disability resources. These people are trained to help you wade through the ton of mind-boggling information. The plans with the best options are likely to have higher premiums, deductibles and co-pays but if they will cover unlimited Benicar, it would probably be worth the extra cost. Best, Meg |
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ShrnHml Member in Phase 2/3 
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For what it's worth: I am on Medicare/Medicaid. Under the new Medicare program I have been assigned to Humana (but can change if I wish). A check of their website (thank you Jillian for "how to") showed that Benicar was in the "limited" category. I called Humana Customer Service to see if Benicar would be available to me at 90 pills per month. The person I spoke with said, "There will be no problem as long as your doctor prescribes it". I should have gotten the guy's name, darnit. Sharon Last edited on Wed Nov 30th, 2005 14:48 by ShrnHml |
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Foundation Staff .
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Sharon, I am insured through a self-funded Humana plan that generally provides excellent coverage. They denied my last Benicar refill unexpectedly and only allowed an override for one 3 month refill. I expect to get a complete denial next time but I'm working with the Humana sales rep now to try to prevent that. I am hopeful for you but I am very skeptical about a claim of unlimited Benicar coverage. The insurance reps are working overtime to sell these policies to senior citizens now and they are often ill informed. I think you can change your Medicaid/Medicare insurer at any time in the future. Best, Meg |
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BARNEY Moderator 
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The other night I went into the program Jillian mentioned and according to all the meds (MP) I would need, it said they would provide the Benicar at the amts I mentioned if I had a letter of necessity from my doc, thus I am stashing all I can get my hands on now just in case they give me a hassle. Should we mention that we will be getting well and they only need to do this for a while? Only kidding. Never give them information more than you have too. Frankly, I am dreading this program because I think it will be a disaster.  Barney  |
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Foundation Staff .
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Barney, I think you are right to be leery of promises made about unlimited Benicar, especially without a hassle. I've spoken with the insurance agent who sold the Humana policy to my husband's (former) employer. He seemed eager to correct my Benicar refill problem and referred me to his 'colleague' in Humana's pharmacy department. When she called, I got a repeat of an earlier excuse that my doctor didn't sent in the correct paperwork and the pharmacy review team needs more information. I played dumb although I knew she faxed them their 'special form' because I got a copy of it from my clinic's medical records. I asked for the new form to be faxed to me so that I can make sure my doctor gets it. She readily agreed. My intent is to ask my doctor if she would like me to save her some time by filling it out for her. That way I can control what is written and doc only has to sign and fax.  Stay tuned.....I believe the insurance industry purposely fragments their services to make it difficult for all but the most savvy and persistent to pursue a denial. This experience and advice from some of my patients made me realize what an asset the insurance agent can be. The person who sold you the policy (in this case my husband's employers who are interested in getting their money's worth) is obligated to help his customers navigate the sytem. When you have trouble with a claim and do not get easy satisfaction from the insurer's reps, contact your insurance agent to complain that the 'product' you purchased from him/her is not delivering the promised goods. The Medicare/Medicaid plan D for meds should work in a similar fashion to any insurance plan for medications. The primary difference is that the cost of the premiums, deductibles and co-pays should be affordable because they are subsidized by the Federal government. You will still be working with the insurance agency you choose and all that may entail.  Best, Meg |
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BARNEY Moderator
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Meg, The reason I say this is going to be a night mare is it is going to cost us out of pocket a minimum of 1/3 of our social security...like Jillian says we might have to buy it without getting involved with Medicare D. How many of us can live on only 2/3 of our social security benefits. Knowing this was coming, I have stashed some Benicar, gotten all the rest of my MP meds free thru needy meds and feel I am all set to finish MP with what I already have on hand. I will buy the Benicar (if I have toooo). I will finish MP come Medicare D or high water. We just have to learn how to survive, just like we did these darn diseases. HANG IN THERE, WE WILL MAKE IT!! BARNEY |
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ShrnHml Member in Phase 2/3
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Any other seniors out there who have tested the murky waters of Plan D. I spent the whole day going back and forth between home (phoning company) and the pharmacy trying to get my Benicar script filled. The plan I chose is Silverscript because they are a Caremark company, and I have read reports here that Ben was easier to obtain through them (in the quantity we need) than through Medco, United, and others. I had done a thorough computer search and comparison of all the companies available to me and felt good about my choice. However, the script would not go through on the pharmacy computer. I came home, called Silverscript, and was told that Ben is not covered on the plain vanilla plan which I have.....just on Silverscript PLUS. However the computer formulary for Silverscrpt says that it is covered on BOTH plans, and I have printed it out. Tomorrow I dig in again. I'm glad perseverance is one of my traits. Sharon |
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BARNEY Moderator
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I put in all my meds into the Medicare Prescription Drug Plan and came up with the Drug Company that I was supposed to use according to them. Since I am low income, I was not supposed to pay a monthly premium. Now the company has sent me a bill for $33.00 a month plus my copays on each of the meds. I called the company and they told me that I picked the wrong one, that it should have been only their basics plan, but the Medicare book says there is no fees for low income. I called Medicare, and went thru 3 different people who agreed with me and filed a complaint against the company. Now here I sit waiting on a person to call me and let me know if they have this straightened out. Cannot get any meds yet unless I pay in full for them upfront and then submit a bill to the company. I told the lady if I had that kind of money I would not be signing up with their plan. I was afraid of this so I did a little stockpile for a just in case. I will be okay for a little while. Is anyone else having problems? HANG IN THERE, WE WILL MAKE IT!!!! BARNEY |
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jillian Member in Phase 2
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Barney, I'm not having the problem, but you may want to call your State's insurance agency for their assistance, phone number is listed in the back of the 2006 Medicare booklet. I've heard they're up more on the problem solving aspect. They were wonderful when I had to contact them. I know the following info is too late for you, but it may help somone else. The Medicare booklet does say that 'dual eligibles' (Medicare/Medicaid) may sign up for ANY program, BUT THAT WAS A GOVERNMENT MISTAKE/MISPRINT (for which they were very sorry in advance because it was bound to cause some people problems who could least afford it ...). It was supposed to say that they could sign up for any program that was at or below the average premium cost in your state of all the plans. Yea, just try and figure that amount out! My room-mate is also a dual eligible so before we investigated companies for her I called the State insurance agency to see which programs were available to her with the premium being paid by the Medicaid program. They gave me the list and she picked one from there after we both did lots and lots of home work. (FYI, here in ND all of policies she was eligible for had Benicar only in limited quantities of 30/month so we know once she gets on the MP this month we need the Docs help. A couple of MPers have posted in the last couple of weeks that they have had the higher Benicar approved through Part D though so we're hopeful!). Hope you can get this straightened out with the least amount of stress possible. 'til later, Jillian |
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mercuryspice Member in Phase 3
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my insurance is not covering benicar at 40 mg every 6 hrs. they will only pay for it once a day. i have united health care rx , medicare part d. does anyone know of other medicare part d companies that are paying for the benicar four times a day. the drs office called insurance company and they won't override it. does anyone know what i should do?? thanks much lisa ps i have public aid so i need a company that deals with them too, i'm in Illinois |
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Foundation Staff .
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Lisa, Another member has reported that Humana is covering Benicar 40mg every six hours under Medicare part D. You can ask the insurer what the appeal process is. If you are getting public aid, you may qualify to get Benicar under the Sankyo Pharma Open Care program. Please see: BENICAR: Where to purchase Benicar for self-pay members Best, Meg |
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ShrnHml Member in Phase 2/3
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Lisa.....have you gone through the appeals process? A letter from your doc explaining the need generally works. Sharon |
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mercuryspice Member in Phase 3
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i just called insurance company last nite and they said i can appeal and have my doc fax a letter to them. Any good ideas on what I can have my doc say in the letter?? any advice would be great. lisa |
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Foundation Staff .
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Lisa, The first request for a prescription authorization may be very simple. You can ask for a copy of the form, fill it out for your doctor and then have your doctor sign and fax it to them. That way you have some control of the process. Be sure to make copies of everything you send and followup with phone calls. Because all your diagnoses are controversial, you may be better off just stating that you have many symptoms of chronic inflammation and Benicar is now being used off-label, at this dosage to reduce inflammation. Do not mention the Marshall Protocol or use the word experimental. They may ask what treatments you've already tried that did not help. If you get a denial, ask the insurer if they have a grievance committee you can appeal to and then find out if they want supporting scientific documentation. My own appeal of an appeal has not yet been decided, but I did send documentation and I'll let everyone know if this worked or not. Best, Meg |
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katydid Member in Phase 2/3
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Lisa, I have Humana Prescription Complete, Medicare part D coverage, and they did okay 4 per day, for 1 year. They did try to double the co-pay, but I called and got that reversed. I used the letter on this site, inserted my name, and my doctor's name, practice name, address, etc., and added a sentence that said something like, "I have prescribed 4 per day, 120 per month for Katherine.", at the end of the pertinent paragraph. I printed it, and my doctor signed it, and faxed it. The letter they have on this site for getting it approved meets all the criteria that insurance companies demand for giving an exception. Just choose the version of the letter that fits your diagnosis. I also sent a letter saying that I had heard that this was really good for inflammation, had worked for others that I knew, that had my disease, and I was on fixed income, and could not afford to buy if I had to pay for meds myself. I used the letter on this site almost exactly, except for above differences, and also where it said 6 to 8 hours, I changed it to 6, period. The letter does not mention the MP at all. I think it is in the must read section for Benicar. Good luck, and if you need name/number of my plan, or other info, let me know! Kathy |
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katydid Member in Phase 2/3
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Lisa, That letter is under Essential Information about the MP, Required Reading, How to obtain the insurance coverage for the full dose of Benicar, about the fourth topic down. Kathy |
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Aussie Barb Research Team 
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Thanks Kathy, links below. Lisa, HOW TO OBTAIN INSURANCE BENEFIT FOR FULL DOSE OF BENICAR Letter of medical necessity & Consent to Treatment form & letter to insurance company & MEDCO refusing Benicar. all best, Barb .... |
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Foundation Staff .
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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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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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mercuryspice Member in Phase 3
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thanks for your help, all of you, you guys are great!!!!! lisa |
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Foundation Staff .
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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 
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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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jillian Member in Phase 2
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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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Foundation Staff .
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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
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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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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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jrfoutin Research Team 
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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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Reenie inactive member
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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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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 inactive member
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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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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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Foundation Staff .
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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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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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Foundation Staff .
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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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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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mercuryspice Member in Phase 3
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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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ShrnHml Member in Phase 2/3
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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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Reenie inactive member
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mercury and Sharon, I'm not exactly sure that trying to get a medication approved for a specific ailment is the right way to go about getting insurance coverage especially since Benicar is being used "off-label" in our case. I believe the best way to go about getting Benicar approved is to add some new information to the table that pertains specifically to the type of drug that Benicar is and how it relates to your condition. For example, Benicar is an ARB, or angiotensin receptor blocker, so... if your Dr was to say that you have a condition, which you do, (Th1 or dysregulated D) whereby you need to block angiotensin and you need to take it in the dose prescribed in order for it to work for your condition, this would be a better route to go. I hope that helps. HOW TO OBTAIN INSURANCE BENEFIT FOR FULL DOSE OF BENICAR Letter of medical necessity & Consent to Treatment form & letter to insurance company Last edited on Sun Apr 23rd, 2006 07:37 by Reenie |
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Foundation Staff .
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Sharon, I'm sorry about your denial but it doesn't surprise me. Reenie is right. The less said about the specific disease that Benicar is being used to treat, the better. Medicare Plan D is a taxpayer-subsided insurance plan administrered by hundreds of insurance companies. Many of them have promised the moon to seniors to get them to enroll. Experts predict that, inevitably, rates will increase and promised benefits decrease as time goes on. Of course, the FDA does not approve drugs for certain indications but it sounds good to the average person. This is the first that I've heard of the "four medicare designated references". You are entitled to have specific information about that in view of this denial. Unless you can find fault with those references, I'm afraid that it will be pretty hard to fight a company that is able to cite federal Medicare rules in their denial Good luck, Meg |
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BARNEY Moderator
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Okay ladies, I got 2 months Benicar and Mino from the prescription d drug plan and then Aetna sent me a letter saying that the first 2 months were a 'gift' and that now we had to get down to facts and that I needed to prove I needed it....so... I copied the LETTER OF MEDICAL NECESSITY @ HOW TO OBTAIN INSURANCE BENEFIT FOR FULL DOSE OF BENICAR that is on the MP site (it is my understanding that a fellow MPers wrote it and it is great). My doctor...first of all was very impressed by it and so was.....Aetna...here is a couple of paragraphs from their letter I received yesterday... "Our records indicate that you are currently taking the following medication which usually requires your physician to request an exception to our utilization management programs: Benicar Tab 40mg Aetna Medicare will continue to cover this prescription for you through December 31, 2006. You have been taking this medication for a period of time and it appears the the medication may be the appropriate therapueutic choice for you." H OOOOOOOOOOOOOOOOOOOOO RAY!!! MP MEDS WON!!! It costs me $5 for 136 Benicar tabs. I am in 7th heaven. The only thing I did to the letter of necessity after I copies it....was put my name in as the patient and add on that I would also need Mino and how it can vary in amounts depending on the place I was in the treatment, anywhere from 25mg to 100mg every other day. At present....I get 45 for $2. Just wanted to encourage others to use the Letter of Medical Necessity on this site and don't add anything much to it especially any more explanation of your disease or how you really use these meds. If you do not have sarc, you would want to change it to CFS, RA or whatever disease you have. I used to be a legal secretary and we always advised the clients when they were going to testify in court to only: Answer the question with as simple an answer as possible and do not add anything to it, seems to be a better way to handle it and not get into trouble. Hope this helps others!!!! HANG IN THERE, WE WILL MAKE IT!!!!BARNEY |
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jillian Member in Phase 2
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A head's up for those of us on Social Security Disability or Retirement--most of the insurance companies are revamping their Medicare Part D drug coverage, formulary and premiums. Good news is that many premiums are a lot lower. But, I've been doing some checking for me on the formulary changes. Benicar is NOT being offered in 2007 by some companies that did cover it in 2006. When I was working with the medicare.gov site this week, it turns out that the formulary info is from 2006, NOT 2007 yet so the comparison on the site is useless. (I'm going to contact them about it next week.) At the moment, it seems the best way to check formularies is to go to the insurance companies directly--just be sure they too have the updated 2007 formulary info!!! (one company I contacted didn't have it yet.) 'til later, Jillian |
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Lilly Member in Phase 2/3 
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Thanks for the info. I am one of those who depend on Medicare D and the company I was assigned is the infamous Medco. So I am looking for a company to change to. If you know of any that DO cover Benicar, please share. Lilly |
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ShrnHml Member in Phase 2/3
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Jillian..........thanks for bringing this to our attention. Lilly...........Unicare covers Benicar for 2006. I don't know about 2007. If you have Medicaid too, they will pay the premiums for the plan.....at least they told me they would. You never know if the information is good though. Best.......Sharon |
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jillian Member in Phase 2
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Well, this morning I decided I had to stop procrastinating and do my Part D research. I must admit that the process this year is much, much, MUCH easier. I ended up calling Medicare with a question (20 minute wait for the answer, but it was worth it), and was given a tip that made the whole process easier. It's called doing a Personalized Search. I'm going to detail below for those of you who may need the help. I'll include tips I found along the way too. What I found critical with this Personalized Search is that if your a dual eligible (Medicaid pays your premium), they'll show you all the plans in your area, including the more expensive ones, and show what your costs would be after Medicare pays the premium. It turned out that Bree, my roomie who's dual eligible, can pay $14 extra per month for a better insurance policy that will give her the 120 tabs of Benicar without an issue. The other plans that were paid totally only covered 30 tabs per month. Needless to say, it's gonna save money!!!! More on that below... When you get to Medicare.gov site click COMPARE MEDICARE PRESCRIPTION DRUG PLANS. On the next screen, in the left column, just below the red box that says 'Don't be late, enroll by 12/8' click Find & Compare Plans. On the next screen do a BEGIN PERSONALIZED SEARCH. Enter your personal information, click Continue. If the next screen asks for a county, select it, click Continue. Medicare will now pull up the information it already has with the name of your current Part D insurer, click Continue. Next click Enter My Drugs. Enter your drug info (I also included some I may need to take in the next year just to be sure they were in a plan's formulary.) Just keep adding drugs until your finished (tip: you can remove them later in the process when comparing monthly costs). When you've added all your drugs, click Continue. Change the drug description if needed, e.g. Beni 20mg to Beni 40mg, and the quantities. (Note: each time you change the drug description the screen will blink as it changes.) Press Continue. With the next screen you can save your drug info so you can come back and not have to redo it. They ask for you to select a 'password' for this list or you can skip the step. Press Continue. Next they'll ask about pharmacies, I skipped this step. Press Continue. Now you'll get a table listing your current plan and the ones available in your state. It lists annual costs, monthly costs, premium costs, etc. (this is where if you're dual eligible you'll see how much extra you'd have to pay if you choose a better plan.) BE SURE YOU CHECK THAT FOR BENICAR YOU DO NOT NEED PRIOR AUTHORIZATION, THERE ARE NO QUANTITY LIMITS AND NO STEP THERAPY. To do this click the name of the insurance company and it'll show you all the drugs you entered before and the plans requirements. When you're at the table, there's a button so you can Add a plan that does meet your requirements to a Favorites list. It'll be moved to just below your current plan. Then once you have those Favorites separated from the ones that don't have good coverage, you can better make a choice. Because I don't trust the system totally, once I narrowed my choices down to a couple of plans, I went directly to their website and checked their formulary to be sure the info at Medicare.gov was correct. PM me if I can be of assistance. 'til later, Jillian Last edited on Thu Nov 16th, 2006 00:25 by jillian |
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ShrnHml Member in Phase 2/3
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Thanks for those good directions, Jillian. I am dual eligible and opted to pay a premium to get a plan where the formulary has no limits on quantity of Benicar. Much to my surprise and delight, Medicare pays the cost. I hope it's that way in your state too, although Medicare, being a federal program, should have the same rules everywhere. ............Sharon |
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Lilly Member in Phase 2/3
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Thank you soooo much, Jillian. I, too, have been procrastinating doing this, dreading the mind-numbing detail and mumbo-jumbo. I did start once at the Medicare site, but gave up for lack of ability to concentrate after a half hour of sifting through the haystack. Which plan did you find for an extra $14/month that pays for Benicar? (Still trying to get away with not doing the research myself ) I'm dual eligible and not too far away, in western Nebraska, so it might work for me, too.Again, thanks a million! And thanks to Sharon, too. From what I could tell, Unicare doesn't cover Benicar in quantities we need, for 2007, but I'm not sure.... I gave up before I could figure it out. (If a person with a college degree can't figure this stuff out, what happens to those with little education? Medicare D..what a travesty. Medicaid paid for Benicar without all this, before....) Lilly, much encouraged by these and other recent developments |
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jillian Member in Phase 2
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Lilly, I PMd you with a couple of plans that I found were good here in North Dakota. Last edited on Thu Nov 16th, 2006 18:19 by jillian |
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ShrnHml Member in Phase 2/3
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Lilly.........if I can horn in on Jillian's thread..... Unicare has three plans. For clarity lets's call them Basic, Moderate, Premium. Basic has restrictions on Benicar, but the other two do not for 2006 and 2007. Rather than sign up on the internet, I found what I wanted on the website and called Medicare directly. They enrolled me in Premium, even though I requested Moderate. When I asked why, she said........as long as the premiums were being paid, it didn't matter. .............Sharon |
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Foundation Staff. . 
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If you are a Medicare beneficiary, you are eligible for a Medicare prescription drug plan (called Medicare Part D). The open enrollment period for Medicare Part D plans is now underway, and ends Dec. 8. This is the time to make a change if you are not happy with your plan. Go the the Medicare website for more information. Some of the Medicare D plans are changing in 2007. To learn more about Medicare Part D and the plans in your area, call 1-800-633-4227. Your state state insurance health program (SHIP) can point you to local resources that offer free customized advice about picking a plan. Visit http://www.eldercare.com or call toll free 1-800-677-1116. Belinda |
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Foundation Staff. .
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To learn more about Medicare Part D and the plans in your area, call 1-800-633-4227 or go to http://www.medicare.gov/. Your state state insurance health program (SHIP) can point you to local resources that offer free customized advice about picking a plan. Visit http://www.eldercare.com or call toll free 1-800-677-1116. Belinda |
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Lilly Member in Phase 2/3
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Thank you Jillian and Sharon! I am now enrolled in Unicare Premium, as of next month. I did it by phone with Unicare after following Jillian's instructions. The phone guy says it will cost me $38/month premium + $3 for benicar; the Medicare comparison website said $9-something, probably what I'll pay after Medicaid pays part of the premium. Either way, it will be a lot better than paying out of pocket, which is what I've done since August. Again, thanks a bunch! You, too, Belinda, but I didn't find the eldercare site helpful. Couldn't find anything pertinent after a couple of clicks, so I gave it up. At 59, I don't think of myself as "elder", anyway.  |
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Foundation Staff. .
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Lily, I agree, that eldercare website doesn't have the help I read it would have. Glad you are all set for 2007. Belinda |
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Foundation Staff .
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Another good source of information about Medicare plan D would be your local Office on Aging. They should have the inside info on what seems to be working for the Medicare recipients in your area. |
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katydid Member in Phase 2/3
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Another plan that will cover Benicar without limits is Sterling. I did check their website to make sure. I sure wasn't going to stay with Humana after they turned others down. To make a good choice, though, you really need to use the comparison tools (input zip code, drugs, etc. as Jillian said about the Medicare site), then check the formulary at the company website. All plans are not available everywhere. Kathy |
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thaiboxer Member in Phase 2/3 
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Where can I find info re: medicare and which plan covers at least the Benicar? I have Sierra Rx. They completely took Beni off of their formulary. thanks |
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VEZ R.N. Health Professional
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BENICAR: Where to purchase Benicar for self-pay members Includes information about countries where Benicar not sold and "Open Care" Program for low income patients Regards, VEZ |
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ShrnHml Member in Phase 2/3
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Thaiboxer...............I have Plan D and have found that Unicare covers Benicar. Caremark and Humana did NOT. ............ Sharon |
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ShrnHml Member in Phase 2/3
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Medicare Part D Benicar alert: Unicare no longer provides Benicar at the doses needed. Try Aetna or call the Medicare 800 number to find companies that will provide. If computer savvy and not brain-fogged, try the Medicare website for companies that have no limitations on Benicar. 1-800-MEDICARE http://www.medicare.gov |
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rebeckah Member in Phase 2 
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I had Community Care Rx and they require step therapy (trying different drugs first). I got sent a letter after they refused coverage of Beni saying I could "send a written appeal to the following address". So, I sent a rewrite of the letter found here signed by my DR, and a personal letter from me. I phoned a month later, they couldn't find my letters. I tried the whole scenario again in December but sent it delivery confirmation this time. They said since they took more than a week to decide my case, they forwarded it to Maximus who is an independant medicare insurance coverage reviewer thingey-do. While on the phone, the CCRx agent said I had to fill out a form requesting a formulary exception. That's not what my denial letter said I had to do. HAD I known and filled out the forms, and got the other drugs filled (but not taken), I may have gotten coverage for Beni in the end. You really need to know what to do to get an exception from your provider. Call them. Talk to different reps to verify. But who needs the aggro? I'm switching carriers. I moved almost 2 years ago & only this month did CCRx send me an updated card (new numbers), yet they're still using my old address. I phoned my new address to them before I even moved here. I am unimpressed with them. Maximus denied it because Benicar hasn't been "used for a medically accepted indication". IOW: it's not on the FDA books that Beni is used to treat sarc. I've used the Medicare website ins. helper thing and found it very easy & helpfull. I also called medicare directly and went through the same process with them & asked more questions etc. Trying to double check things. I must've got a new hire, she didn't know what she was doing. Also, if you're "dual eligible" meaning you have both medicare and medicaid, then you can change insurance providers at "any time". Yet, on some insurance websites I've seen dual eligibles may only switch from Nov-March 31st. So, check individual provider websites to be sure. |
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ShrnHml Member in Phase 2/3
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I went through the Maximus process too and was also denied. I do not believe they are "independent" of the drug companies, especially with the current administration favoring the drug companies. Also, even if the Medicare website says there are no restrictions on Benicar for a certain company, that is no guarantee I found. I wonder if there is a way to call the company and get it in writing before joining or if that would just call attention to it. Because I am dual eligible, I have been able to make changes at will and am now on my fourth company. Unicare was the only one that actually paid, but now they have cancelled the plan I was on. That's why I went to Aetna. |
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rebeckah Member in Phase 2
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Twice I called the insurance company I want to switch to & got confirmation that there are no restrictions to Benicar coverage. I also checked through the medicare website as well as the insurance company's online formulary. All said no restrictions. So I should be ok now. It's good to be thorough. I also found out that medicaid tells you what your copays will be per script. It's written on the medicaid acceptance letter. Mine was in very small print at the bottom. The insurance compnay has no idea what each persons copay is. Switching companies was very quick and easy. The customer service of my new company (Silver Script) FAR exceeds what I was getting at CCRx too. & that matters to me as well. But wow. four times is alot to change companies. It's good to know you were able to do that without a penalty. I think the rep said we can only change providers once a month. |
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ShrnHml Member in Phase 2/3
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missrebeckah....keep us informed about how well SilverScript does. I used them two years ago, and here is what I posted about it on January 3, 2006: ...........I spent the whole day going back and forth between home (phoning company) and the pharmacy trying to get my Benicar script filled. The plan I chose is because they are a Caremark company, and I have read reports here that Ben was easier to obtain through them (in the quantity we need) than through Medco, United, and others. I had done a thorough computer search and comparison of all the companies available to me and felt good about my choice. However, the script would not go through on the pharmacy computer. I came home, called Silverscript, and was told that Ben is not covered on the plain vanilla plan which I have.....just on Silverscript PLUS. However the computer formulary for Silverscrpt says that it is covered on BOTH plans....... Sharon |
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ShrnHml Member in Phase 2/3
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My experience with Aetna has been disillusioning. This is the most intrusive company I have tried yet. I believe they have implemented a new "control" policy on every medication and are no longer operating as as before. If you want to know more, please PM me. ........Sharon |
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Foundation Staff .
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Jillian writes: I must tell you that as much as I appreciate that Medicare now has drug coverage, I dread this time of year as I must double-check each year that the insurance company I choose has UNLIMITED coverage for Benicar. So far, my room-mate, also on the MP, and I have done okay and not had any problems. She is dual eligible (Medicare/Medicaid), I am not. As Sharon posted on Oct 4th, go to Medicare.gov and do a personalized search. I've just gone there and although sign up doesn't begin until November 15th, you can start searching for a policy using the Formulary Finder. Once you've entered your drug infomration into the Formulary Finder, Medicare will give you a list of possible policies. You must go one by one through the list (by clicking on the name of the plan) to see if they offer unlimited Benicar. How do you know that?, see below. The policy I've had for the past two years is no longer available. Each year there are fewer and fewer policies with unlimited Benicar, and many of these have the higher premiums... This year, for me, there are ONLY 3 different companies offering 5 plans that initially come up with no limits on Benicar! I'm preparing that by next year none will be available and I'll have to fight for coverage, which I'm not sure my doc will do! IMO, very important things to consider about the list the the Formulary Finder will give you: - You most probably want a PDP Plan Type (Precription Drug Plan). The MAPD is a managed care plan that's like a HMO. - You must be sure that the plan lists NO in any of the plan limitations/restrictions (Prior Authorization, Quantity Limits, Step Therapy). - Then, once the information is available (not yet, too early), you'll need to dig more to find out what that specific policy covers, i.e., the cost of monthly premium, the deductible, the co-pay, how do they handle the coverage gap, etc. I've done that in the past by going to the insurance company's website and printing out their formulary to double-check the status of Benicar. I would imagine this earliest this information will be available is November 15th, when we can sign up for a policy. 'til later, Jillian from North Dakota |
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