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tom
Member in Phase 3
| Joined: | Mon Sep 12th, 2005 |
| Location: | New York USA |
| Posts: | 187 |
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Posted: Tue Nov 29th, 2005 19:52 |
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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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CFS 125D50, Ambien NoIRs Ph2 03/06 Ph3 10/06 last 25D22 Jan06
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Meg Mangin R.N.
Research Team (on leave)
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Posted: Wed Nov 30th, 2005 00:07 |
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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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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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jillian
Member in Phase 2
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Posted: Wed Nov 30th, 2005 00:40 |
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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 00:48 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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Meg Mangin R.N.
Research Team (on leave)
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Posted: Wed Nov 30th, 2005 01:29 |
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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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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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ShrnHml
Guest
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Posted: Wed Nov 30th, 2005 11:41 |
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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 11:48 by ShrnHml
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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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Meg Mangin R.N.
Research Team (on leave)
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Posted: Wed Nov 30th, 2005 12:12 |
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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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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: Wed Nov 30th, 2005 23:30 |
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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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64jointsarc77skinsarc80lungsarc81asthma/migranes
95rkidneyremoved(cyst)diabetic/gallbremoved,96
totalhyst(cysts,endom)01fibro,Benicar20mg@3hrs, xtra as needed, Mino25mg @other day
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Meg Mangin R.N.
Research Team (on leave)
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Posted: Thu Dec 1st, 2005 00:51 |
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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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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: Thu Dec 1st, 2005 01:02 |
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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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64jointsarc77skinsarc80lungsarc81asthma/migranes
95rkidneyremoved(cyst)diabetic/gallbremoved,96
totalhyst(cysts,endom)01fibro,Benicar20mg@3hrs, xtra as needed, Mino25mg @other day
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ShrnHml
Guest
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Posted: Wed Jan 4th, 2006 04:02 |
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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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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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BARNEY
Member in Phase 3
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Posted: Sat Feb 4th, 2006 03:49 |
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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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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 Feb 4th, 2006 15:35 |
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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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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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mercuryspice
Member in Phase 3
| Joined: | Fri Mar 4th, 2005 |
| Location: | Chicago |
| Posts: | 184 |
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Posted: Thu Feb 9th, 2006 19:27 |
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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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Lyme 25d 11, 125D44 25D11 Ph1 Sep06 ModPh2Jan07 Ph2Oct 07 Ph3May08 motrin flexeril wellbutrin prozac ativan NoIRs lite exp r/t to school
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Meg Mangin R.N.
Research Team (on leave)
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Posted: Thu Feb 9th, 2006 20:28 |
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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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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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ShrnHml
Guest
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Posted: Sat Feb 11th, 2006 03:45 |
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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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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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mercuryspice
Member in Phase 3
| Joined: | Fri Mar 4th, 2005 |
| Location: | Chicago |
| Posts: | 184 |
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Posted: Sat Feb 11th, 2006 12:00 |
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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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Lyme 25d 11, 125D44 25D11 Ph1 Sep06 ModPh2Jan07 Ph2Oct 07 Ph3May08 motrin flexeril wellbutrin prozac ativan NoIRs lite exp r/t to school
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Meg Mangin R.N.
Research Team (on leave)
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Posted: Sat Feb 11th, 2006 12:38 |
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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
____________________
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: Sat Feb 11th, 2006 17:54 |
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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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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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katydid
Guest
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Posted: Sat Feb 11th, 2006 18:14 |
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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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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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Aussie Barb
Research Team
| Joined: | Thu Jul 22nd, 2004 |
| Location: | Australia |
| Posts: | 19456 |
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Posted: Sat Feb 11th, 2006 19:09 |
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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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Barb: Dx Inflammatory Disease Endocrine Imbalance 2003| 24+ years not Dx| ABCofMP
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