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Reenie
inactive member
| Joined: | Wed Jul 21st, 2004 |
| Location: | Phoenix, Arizona USA |
| Posts: | 3373 |
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Offline
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Posted: Sun Apr 23rd, 2006 04:34 |
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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 04:37 by Reenie
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Meg Mangin R.N.
Research Team (on leave)
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Posted: Sun Apr 23rd, 2006 21:58 |
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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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Nothing contained in this site is or should be considered, or used as a substitute for, medical advice, diagnosis or treatment by your physician.
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BARNEY
Member in Phase 3
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Posted: Tue May 9th, 2006 22:36 |
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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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64jointsarc77skinsarc80lungsarc81asthma/migranes
95rkidneyremoved(cyst)diabetic/gallbremoved,96
totalhyst(cysts,endom)01fibro,Benicar20mg@3hrs, xtra as needed, Mino25mg @other day
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jillian
Member in Phase 2
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Posted: Sat Oct 28th, 2006 20:12 |
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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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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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Lilly
Member
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Posted: Sat Oct 28th, 2006 22:51 |
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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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ME/CFIDS Prozac Wellbutrin Trazadone NADH.Noirs avoiding D,sun from07/04;25D=36;Ph2 restart Sep06. Ph3 03/07
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ShrnHml
Guest
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Posted: Sun Oct 29th, 2006 03:32 |
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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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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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jillian
Member in Phase 2
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Posted: Wed Nov 15th, 2006 17:52 |
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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 Wed Nov 15th, 2006 21:25 by jillian
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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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ShrnHml
Guest
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Posted: Thu Nov 16th, 2006 03:47 |
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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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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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Lilly
Member
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Posted: Thu Nov 16th, 2006 13:00 |
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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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ME/CFIDS Prozac Wellbutrin Trazadone NADH.Noirs avoiding D,sun from07/04;25D=36;Ph2 restart Sep06. Ph3 03/07
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jillian
Member in Phase 2
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Posted: Thu Nov 16th, 2006 15:18 |
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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 15:19 by jillian
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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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ShrnHml
Guest
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Posted: Thu Nov 16th, 2006 23:34 |
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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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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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Belinda
Research Team
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Posted: Tue Nov 21st, 2006 05:21 |
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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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Belinda
Research Team
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Posted: Tue Nov 21st, 2006 05:59 |
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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
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Posted: Mon Nov 27th, 2006 18:54 |
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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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ME/CFIDS Prozac Wellbutrin Trazadone NADH.Noirs avoiding D,sun from07/04;25D=36;Ph2 restart Sep06. Ph3 03/07
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Belinda
Research Team
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Posted: Mon Nov 27th, 2006 23:33 |
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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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Meg Mangin R.N.
Research Team (on leave)
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Posted: Wed Nov 29th, 2006 00:08 |
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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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Nothing contained in this site is or should be considered, or used as a substitute for, medical advice, diagnosis or treatment by your physician.
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katydid
Guest
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Posted: Tue Dec 12th, 2006 01:24 |
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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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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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thaiboxer
Guest
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Posted: Thu Aug 16th, 2007 08:08 |
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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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Thai: CFS 7yrs Pneumonia Rickettsia FeverUO exercise intol, musc twitch fatigue/ Testost subling Jan: 1,25-D 65, 25-D 32/NOIR/Beni Comm Jan05 20mg 3hrs/2abx May05/Q Mar05/probiotics
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VEZ R.N.
Board Staff
| Joined: | Fri May 19th, 2006 |
| Location: | Ohio, USA |
| Posts: | 2469 |
| Status: |
Offline
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Posted: Thu Aug 16th, 2007 09:19 |
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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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lung gran x13 yrs neuro cardiac smp chronic cough joint pain TMJ pain tinnitus Factor V Leiden| armour probiotic|lowlux home NoIRs 6/30 Beni q4+prn 8/28 mino| 6/30 1,25D-58.3 25D-33.6| TSH-10.6 12/16/06 25D-9.6 TSH-8.63 8/06-25D=7|
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ShrnHml
Guest
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Posted: Thu Aug 16th, 2007 13:07 |
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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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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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