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carol
Support Team
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Posted: Mon Sep 1st, 2008 10:09 |
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Lee wrote: My co-pay for my ct scan was 900.00. Never-ever have we had a co-pay that high!
Lee:
This statement caught my eye. Was this a co-pay or a bill from the hospital? I saw a TV news story recently on the the practice of "balance billing", where insurance companies weazel out of paying their share to hospitals and labs, then these organizations pass the unpaid costs on to the patients. It's not legal.
In any case, I hope you will appeal, appeal and appeal some more. And PLEASE think about this when you vote in November.
Carol
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rheumatoid arthritis dx '96...started MP 8/11/04...initial D tests: 25-D=32; 1,25-D=65...10/07 entered Phase 5...Xodol daily, Valium and Tramadol occasionally, all for pain...last 25-D=7 (10/09)...Benicar only, no abx
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Lee
Member
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Posted: Mon Sep 1st, 2008 16:07 |
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Thanks Carol! This is our co-pay and we are trying to find out exactly why it is so high too. I have heard alot of bad things about our new insurance through our new dr's .....a little too late .... Lee
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MP-Feb05 ABX Breaks 7mth, 18mth,3yr,5yr 2003 Sarc, Hyper-flex FM, Hashimotos, COPD, skin, joint pain and Glaucoma
2010 D25-4.8
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cwylie1
member
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Posted: Sun Sep 7th, 2008 02:52 |
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Sorry this is long...Another Medco denial!
Thursday at work I was called by Medco and essentially harassed by some pharmacist (the 4th pharmacist to do this in as many months) telling me the requested dose for Benicar was above FDA approval. I countered that indeed it wasn't and that they had paid for my prescription at a retail pharmacy so what was the problem with the 3 mo. mail in refill. She wanted to know what it was prescribed for and I told her hypertension (have that Dx) but again she went on about needing to try other meds first, which I had a few years ago and that this one (Benicar) was working at the prescribed level and that I wanted to leave it as it was. I said my Doc. was within her legal rights to prescribe such a level (3x/da and she gives us samples for the 4th dose) and that Medco couldn't tell her how to prescribe. After a point I said that if they denied my claim I would report them to the state (Illinois was part of the previous lawsuit). She said that was w/in my right and that she was sorry she upset me. She kept asking again about the excessive amount and finally I just told her to talk to my doctor. She said she had called but they hadn't returned the call.
Later that night I saw that my anticipated shipment of Benicar was changed from 9/8 to 9/11 then on Friday the request was denied d/t not using that medicine for the 'diagnosis'!?!?!? Not being sure what they meant by the 'diagnosis' I emailed them saying I had an HTN dx, had tried other HTN meds previously and that Benicar was working for me at the prescribed level. I also emailed my doc to see if Medco really had contacted them. Perhaps someone at the doc's office offered more info other than HTN. We have had problems with communication and the nurses there. Phew! This about wears me out. Haven't hear bace from my doc. Will call her on Monday or go to the office to try to get more samples to last us and get another order.
So right now we have no insurance coverage for the Benicar and with 2 of us on the MP the cost will be pretty high. I am checking the internet for wholesale pharmacies and the best I found was for 90 tabs of 40mg for $122, which would not break the bank so we may have to do the self pay route. By 'mistake' my doc first sent in a script for 1x/da 40 mg which Medco did fill. That script is still online so I may continue with that for $65 for 90 tabs which is a 3 mo prescription. It all helps.
Another member told me that after jumping through all the hoops, he has been allowed to resume ordering retail with reimbursement thru Medco and a different co-pay than the mail in amount. Is anyone else being able to receive MP level Benicar coverage through Medco?? I plan to file a complaint with the State of Illinois Insurance Board. Do you have any info on how best to do that?
Thanks for all your help and all you do.
Carol 
Last edited on Sun Sep 7th, 2008 02:54 by cwylie1
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Migraines RLS MCS ADD HTN Ph1Jun08 Ph2Aug08, 4/4/09 25D23, NoIRs low lux home cover up lite exp r/t work. Bovine Thyroid 130mg, Prog. cream 0.1mg.qhs., fluoxetine 10mg.q.d.
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goobygirl
member
| Joined: | Tue Jul 24th, 2007 |
| Location: | Michigan USA |
| Posts: | 160 |
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Offline
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Posted: Sun Sep 7th, 2008 07:52 |
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Yes, Medco will let you go to Walgreen's and get if filled by them for 3 months. Lots of times they will give you about 10 small bottles, not a problem.
I don't have the exact info, but you should write the Illinois insurance commission AND the state attorney general (lisa madigan). I got a reply back from the state attorney general. I don't recall what it said, but it might do you good to note other people have written them about this issue (I'd be happy to give you more info if you PM me so you can get a copy of my letter, if need be).
Also, just try asking them to fill it at a retail location. They will give you this run around, but after getting my employer's HR involved, it got resolved.
Threatening to sue seemed to help, and writing the IL insurance commission and attorney general.
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FM, Hashimoto's, sleep apnea, TMJ, endometriosis, migraines, carpal tunnel; initial testing: 125D 24.2 pg/ml, D25 - 33.5ng/ml; last test 12/6/09: 25D 8; mp began 11/07; 100 mcg Cytomel, 5 mg Valium as needed and for sleep.
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cwylie1
member
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Posted: Sun Sep 7th, 2008 18:53 |
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Thanks goodbygirl (I loved that movie),
Yes, I would appreciate a copy of the letter you sent. We do really need to keep on top of these people to do the job of filling prescriptions and not fighting with the consumer.
Thanks,
Carol
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Migraines RLS MCS ADD HTN Ph1Jun08 Ph2Aug08, 4/4/09 25D23, NoIRs low lux home cover up lite exp r/t work. Bovine Thyroid 130mg, Prog. cream 0.1mg.qhs., fluoxetine 10mg.q.d.
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DThomas
member
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Posted: Mon Sep 8th, 2008 16:40 |
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| I has the same expierence as Goodbye girl. Medco fought me on the Benicar, but eventually, after threats to go to the DOL (my company is self insured) and getting my HR department involved I got approval to get Benicar through retail rx at my regular co-pay. It would be cheaper for the 90-day supply, but I got really tired of fighting and it would only save me about $5 a month. I have a lot of info too, so if you need more backup just send me a pm.
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Sarcoidosis lungs, skin, throat, sinus, 25D<4 Ph1Oct06 Ph2Jan07 Ph3Jul07 Synthroid Wellbutrin Systane eye drop albuterol inhaler Tylenol light r/t working NoIRs cover up low lux home
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cwylie1
member
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Posted: Tue Oct 7th, 2008 07:46 |
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After being refused by Medco with their mail order system, I got another script from my MD, went to a retail pharmacy and Medco paid it at the higher co-pay without so much as a phone call!!! I immediately called my MD to get another script for my husband and they paid that too!! The pharmacist did call my MD to ensure the 3x/da is what she actually was wanting and there was no trouble.
The pharmacy tech thought it went thru because it was a new script at a different pharmacy. Will have to see as we continue to refill the scripts. I will continue to fill the Benicar locally and pay the higher copay as it is a brand name item.
Keeping my fingers crossed! 
Carol
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Migraines RLS MCS ADD HTN Ph1Jun08 Ph2Aug08, 4/4/09 25D23, NoIRs low lux home cover up lite exp r/t work. Bovine Thyroid 130mg, Prog. cream 0.1mg.qhs., fluoxetine 10mg.q.d.
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jsledge
Member
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Posted: Fri Nov 21st, 2008 16:23 |
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Hello All,
I am now among the unfortunate ones dealing with Medco. My wife's company changed from BCBS to United in Oct, and switched the pharmacy benefit from Walgreen's to Medco. Prior to the switch, I had no problems getting my 90-day supply of Benicar from Walgreen's mail order service. My Dr. faxed in the script and they simply denied it claiming that my insurance plan only provides for 90 pills over a 65 rolling-day period. Hmm... that's not at all what it says on the website. So, the drama begins.
The rep said I needed to file an appeal with United, and the email response said I just need to get the higher amount approved by having my Dr. contact them. We'll see. I'll keep you posted as to what I find out next week. In the mean time, if anyone has a suggestion other than those listed in recent posts, feel free.
John
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Sarcoidosis/lungs |HTN |Ph1Mar08 |NoIRs |covered up |low lux |25D 14 ng/mL Mar08|1,25 D 25 pg/mL |Ph2Jun08 |25D 8 ng/ml Jun08 |25D 5.1 ng/ml Nov08 |Ph3Dec08 |2/09: 25D 4.4; 1,25D 29.5 pg/ml |Xyrem | 25D 5.5 9/09 |12/09: 25D 5.8; 1,25D 20.2
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Grey Fox
member
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Posted: Mon Aug 31st, 2009 19:54 |
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This month I have been forced to change insurance from United Health Care to Aetna, since my retiree insurance now only has Aetna coverage.
The good news is no longer having to deal with Medco.
The bad news is now having to deal with Aetna Pharmacy Management.
I received a letter from Aetna Pharmacy Management today that states:
"This letter is to inform you that we have provided you with a temporary supply of Benicar 40mg tablets.
This drug will be covered only if you first try certain other drugs on our formulary, as part of a step therapy program. We have provided you with a 30 day supply, but we will not pay for an additional fill unless you try other drugs on our formulary first or you obtain an exception to the step therapy requirement from Aetna."
Has anyone else has had this problem with Atena and what is the most effective argument to use to get an exception to Aetna's step therapy requirement?
I have read the 'How To Obtain Insurance Benefit for Full Dose of Benicar' thread.
-GF.
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Chronic renal calculi a-fib HTN sinusitis|125D57,77,81,41,40,30,53 Apr12|Ph1 Aug07 ModPh2 Nov07 Ph2 Jan08 Ph3 Aug08|limited outings|25D44,16,24,34,7,29,38 Jun11.
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Lee
Member
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Posted: Tue Sep 1st, 2009 00:44 |
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| I had something similar happen to me when I tried to get an rx filled for Lyrica with Aetna. It took two docs and alot of back records to do what they asked for this med. Then I found out Lyrica was bad medicine anyway .... I am half afraid to try and fill my Benicar and it is time to do it!!! Makes me wonder if maybe Obama is on the right track?! Good Luck! Lee
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MP-Feb05 ABX Breaks 7mth, 18mth,3yr,5yr 2003 Sarc, Hyper-flex FM, Hashimotos, COPD, skin, joint pain and Glaucoma
2010 D25-4.8
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YoKoMo
Member
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Posted: Thu Jul 1st, 2010 21:39 |
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I'm going to take another run at my healthcare provider (Premera) to see if I can get them to grant me an specific (just for me) "override" for 160mg Benicar/day. This would override Medco's refusal to fill the Rx.
Here my Qs and their As (omitting numerous explanations I provided)
My request in this post is for where I might find any backup data for item 2.
My request...
Their refusal--a list of stipulations...
My request for clarification:
Q1) For which if the stipulations is the override being rejected?
Premera: There is insufficient outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate its safety and effectiveness for the disease or injury involved Q2) What defines “sufficient outcome from controlled clinical trials…”?
Premera:
Credible scientific evidence includes but is not limited to reports and articles published in authoritative peer-reviewed medical and scientific literature, generally recognized by the relevant medical community and assessments and coverage recommendations published by the Blue Cross and Blue Shield Association Technical Evaluation Center. Q3) What group or person interprets this and makes the final call?
Premera:
In making this determination, Premera takes into account the results of a review by a panel of independent medical professionals. Panel members will be selected by Premera. The panel will include professionals who treat the type of disease involved.
Any links or pointers to gathering current, relevant data for issue number 2 would be greatly appreciated.
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CFS food sensitivities arthralgia 125D37 NoIRs 1hr lite/day covered up Ph1 Dec07 Ph2 Feb08 25D9 Mar08, 25D6 Aug08, 25D6 Oct09
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Joyful
Foundation Staff
| Joined: | Sat Jun 9th, 2007 |
| Location: | North America |
| Posts: | 7018 |
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Offline
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Posted: Fri Jul 2nd, 2010 09:49 |
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Kelly, this is an obfuscation by your medical insurance provider. 
If your doctor says you need this, who else is aware of your case history and individual needs? Not a panel of experts surely.
But good of you to keep at them!
Let's break this down into two parts:
"substantiate its safety "
"and effectiveness"
... "for the disease or injury involved"
Use the MPKB to search for "olmesartan safety" and maybe the published papers/presentations list for the effectiveness part.
There is no doubt that it is safe. The intial (pre-approval by FDA) studies showed that.
As for effectiveness, Tom Perez's symptom improvement presented at the AI conference in Porto presents a chart showing results for CFS. The response rate is far better than many, many accepted drugs. If your doctor cites this data in a letter, that seems like best way to press the point.
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Forums • Be Kind, We Are All Fragile • Conferences
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YoKoMo
Member
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Posted: Fri Jul 2nd, 2010 17:09 |
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Where might I find the "Tom Perez's symptom improvement presented at the AI conference in Porto"?
I'm looking for data in written form of course.
Thanks
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CFS food sensitivities arthralgia 125D37 NoIRs 1hr lite/day covered up Ph1 Dec07 Ph2 Feb08 25D9 Mar08, 25D6 Aug08, 25D6 Oct09
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Dr Trevor Marshall
Foundation Staff
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Posted: Fri Jul 2nd, 2010 21:00 |
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You also want Greg's Ljubljana transcript:
http://autoimmunityresearch.org/abstracts/Ljubljana_Blaney_transcript.pdf
http://AutoimmunityResearch.org/transcripts/ICA2008_Transcript_TomPerez.pdf
below are some other URLs from my collection
..Trevor..
http://autoimmunityResearch.org/preprints/BlaneyAnnals2009Preprint.pdf
http://autoimmunityResearch.org/preprints/ProalAnnals2009Preprint.pdf
http://autoimmunityResearch.org/preprints/WaterhouseAnnals2009Preprint.pdf
http://AutoimmunityResearch.org/preprints/AR-Proal-Metagenome.pdf
http://AutoimmunityResearch.org/preprints/AR-Albert-VitD.pdf
http://TrevorMarshall.com/BioEssays-Feb08-Marshall-Preprint.pdf
http://www.townsendletter.com/Jan2009/vitaminD0109.htm
http://books.google.com/books?id=oSl8VY33634C&pg=PA1#v=onepage&q=&f=false
http://www.tbiomed.com/content/3/1/1
http://www.futuremedicine.com/doi/pdf/10.2217/17410541.6.2.143
http://www.thelancet.com/journals/lancet/article/PIIS0140673606695093/fulltext
http://www.aacijournal.com/content/5/1/8/comments#384657
http://autoimmunityResearch.org/abstracts/Ljubljana_Albert_Poster.pdf
http://autoimmunityResearch.org/abstracts/Ljubljana_Bipolar_Poster.pdf
http://AutoimmunityResearch.org/transcripts/CMBF_2009_Dalian_Transcript.pdf
http://AutoimmunityResearch.org/transcripts/Prague_2009_MP_Transcript.pdf
http://AutoimmunityResearch.org/transcripts/Prague_2009_Science_Transcript.pdf
http://AutoimmunityResearch.org/transcripts/WCG2008_Keynote_Transcript.pdf
http://AutoimmunityResearch.org/transcripts/WCH_2008_seminar_transcript.pdf
http://autoimmunityResearch.org/transcripts/ICA2008_Transcript_TrevorMarshall.pdf
http://AutoimmunityResearch.org/transcripts/ICA2008_Transcript_AmyProal.pdf
http://AutoimmunityResearch.org/transcripts/ICA2008_Transcript_GregBlaney.pdf
http://AutoimmunityResearch.org/transcripts/metagenomics2007.pdf
http://AutoimmunityResearch.org/transcripts/dmm2007-harvard.pdf
http://AutoimmunityResearch.org/transcripts/dmm2006-karolinska.pdf
http://mpkb.org/doku.php/home:publications:marshall_fda_cder_2006
http://autoimmunityresearch.org/fda_visiting-professor_7mar06_144dpi.pdf
http://www.autoimmunityresearch.org/transcripts/arasaki_jssog_2006.pdf
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