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» LymeNet Flash » Questions and Discussion » Medical Questions » Medco won't fill lyme scripts.

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Author Topic: Medco won't fill lyme scripts.
burnsjw
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Medco mail in recently said they would not fill my lyme antibiotics anymore. Anyone else having this kind of a problem?
Posts: 211 | From In my house | Registered: May 2007  |  IP: Logged | Report this post to a Moderator
lou
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Yes, quite a few people.

Read this: http://www.lymedisease.org/news/lymepolicywonk/370.html

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burnsjw
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Is this recently that Medco is doing this to lyme patients? Are they having trouble with local pharmacies filling their scripts? Are some insurance companies now refusing to pay for lyme patients antibiotics?
Posts: 211 | From In my house | Registered: May 2007  |  IP: Logged | Report this post to a Moderator
onbam
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Didn't know they were allowed to do this.
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Haley
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Very interesting. I just signed up for Medco and they questioned my script from my doctor. I have never had that happen before. Somehow my order got out the door. Thank God.
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Lemon-Lyme
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Hmm... I didn't know it was legal for Medco to deny medications like that. How do they even know the antibiotics are for Lyme?

And can you get them filled at a local pharmacy (not mail order) instead?

I have Medco, and haven't run into a problem with them denying meds. But they did, sort of sneakily, change Omnicef on me several months ago, and would only fill 10 day prescriptions -- made me get 3 refills a month locally -- but doc changed me to Ceftin to get around that. Now I wonder if they'll do the same to Ceftin eventually.

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lymebytes
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It might be different in different states. For instance in some states, such as California, doctor's are protected by law to prescribe and treat all diseases, including lyme as they see fit.

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Tincup
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If you haven't had Medco problems yet, please be aware you may soon have them no matter what state you are in or what laws you have, so be prepared.

They are using and specifically citing the IDSA Guidelines to deny filling prescriptions for their members.

They can and are getting away with it.. for now.

If you are denied be sure to appeal and contact the insurance officials in your state to report it. The more complaints they have, the deeper they go to address it.

Keep your documentation and get everything in writing. My bet is there will be a class action filed ... but DO pursue it on your own... don't wait for help from others.

[Big Grin]

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littlebit27
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I have no idea who these Medco people are but I do know that is crap! How can these people just refuse to dispense medicine? They are not the ones writing the scripts nor do they have the power to write the script, right?

Is this a mail order company or something? Oh some people are just really stupid.

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burnsjw
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Thanks everyone for all your help. I do know of a few who it is happening to. Like Tincup says , they are and can get away with it. I think they will cont to do this. They are using the new IDSA guidelines. Believe me the ins. companies all know who treats lyme. If you take high doses for a long time , of antibiotics, that is who I think they target. Medco is also probably helping ins. companies target our drs. Our drs do not have time to sit in their office writing letters to medco fighting for every patient's meds. Thanks everyone
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merrygirl
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I have medco and go to a pharmacy. Luckily no probs yet.

I have another ins anyway but medco is cheaper copay

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minimonkey
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It is not a mail order company, per se, but an option provided by insurance... my insurance plan uses it. If you fill you prescriptions by mail, it costs you less than if you go to the pharmacy.

There is a lot of pressure from my insurance company to fill meds that way. Since it clearly states in the literature for Medco that it is designed to keep costs down (and if you read the fine print, it isn't the patients' costs with which they are concerned!) I have refused to sign up for it.

--------------------
"Looks like freedom but it feels like death..
It's something in between, I guess"

Leonard Cohen, from the song "Closing Time"

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burnsjw
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Right, medco contracts with your ins. to keep costs down. It is a new marketing program they offer. You are smart not to use medco. Some people who were cut off by Medco then started having trouble with their local pharmacy filling scripts. The local pharmacy then would only fill 14 days worth, or some kind of a portion and you have to pay cash for the rest of the month.
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Haley
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My understanding is that they buy large quantities at a time and that is how they keep the cost down. Sort of like a Costco for medicine.

This thread makes me nervous. I have only placed one order with them. I did this because I couldn't afford Mepron and Malarone through my pharmacy. My local pharmacy has never asked me one question about the plethora of medicine I receive.

I would hate to have a red flag or my Dr. have a red flag because of this company.

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burnsjw
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If your dr. treats a large number of lyme pts., they know who he is. Just purchasing one med. through Medco doesn't seem like you would be targeted, but I don't know. One person who was Medco cut off wasn't receiving expensive meds for lyme. Once I was cut off from Medco, a local pharmacy is now calling my dr. everytime I refill a script. I really feel for my dr. My dr. has been nice to me about it. Some drs might not want to be bothered with all the extra work. Plus, like you said , it does red flag the dr. as well.
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lou
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This is the way insurance companies are now using to avoid providing meds for lyme patients. Their contract pharmacists don't agree with the treatment, cite IDSA guidelines. That way there is no insurance appeal. You can be sure that this is being done at the request of the insurance company that is using Medco.

But we need to be telling our state insurance commissioners and attorneys general that this is happening. And I think we ought to be filing appeals with the insurance company anyway. Call them on this rotten ploy.

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lou
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And Medco started doing this even before the IDSA bogus guidelines were rubberstamped, because the insurance companies knew in advance that the IDSA would not change. And why not, since the IDSA announced in advance that they would not change!
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Nutmeg
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I think our insurance uses Medco too, but I don't take Rx drugs very often. Scary that they have that much power and control.

The way they do it now is you can have the first 3 prescriptions filled locally at a pharmacy (I mean one Rx and two subsequent refills of the same drug), then you have to use the mail-order service or else pay out of pocket.

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TerryK
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If your insurance company contracts with medco then all of your prescriptions are billed through medco whether they are processed through the mail-in pharmacy or through your local pharmacy. Medco told me this and I verified it with my pharmacy.

Medco will tell you that they do not decide what is and is not covered. They process the claims with the parameters that your insurance company gives them. They do not flag anything for the insurance company based on treatment guidelines blah blah blah.

What they don't tell you is all the wonderful programs that they have in place to manage costs for your insurance company.

Oh yeah, they will also provide your doctor with a list of all medications that you are getting from any other doctor so if you were thinking you would not tell your doctor that you are being treated for lyme disease, think again.

Their website tells it all.

http://tinyurl.com/2dvto67
This is presented as a voluntary service to help the doctor. My guess is that they pass the guideline flags on to the insurance company.

Clinical management programs
Many of Medco's clinical management products help to lower plan costs and improve quality of care by voluntarily engaging physicians and pharmacists in addressing inappropriate prescribing, dispensing and use.

...

Retrospective DUR (RDUR) - The RDUR program retrospectively identifies opportunities to:
Enhance compliance with clinical practice guidelines. You may receive patient-specific information from Medco which may highlight items relating to safety and efficacy. Please review this information to determine if any changes in therapy are warranted.

Also this:
High utilization management - The program detects possible fraud and abuse retrospectively. It is designed to identify patients who meet criteria indicating possible excessive utilization or, in some cases, abusive utilization.

I couldn't make links to some of the other stuff because when I clicked on them I would get a "medco timed out" error. Go here
http://www.medcohealth.com/medco/corporate/home.jsp

Then go to the medco pharmacy link in the page in order to read more.

Here are some things from that page.
We have a dedicated team of pharmacists who focus solely on drug utilization reviews to make sure the medication your member has been prescribed is the right drug, in the right dose, at the right time.

Personally, I think adherence to guidelines that benefit insurance company coffers is right in line with Obama's new healthcare plan and will be the norm for all insurance companies very soon.

Terry

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Haley
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Terry Said:

If your insurance company contracts with medco then all of your prescriptions are billed through medco whether they are processed through the mail-in pharmacy or through your local pharmacy. Medco told me this and I verified it with my pharmacy.

Terry - As far as I know Med co didn't even know I existed until I signed up with them. Do you mean that everything was going through them with my insurance company even before I signed up for the program?

I would think that they would need a medical release form from me before they start informing my doctors what I am taking.

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ConnieMc
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Medco is the administrator for drugs for my BCBS insurance, which is the state employees plan for my state. They deny lots of things. I have had them question Provigil and the generic for a PPI for gastric reflux just in the last few months.

If they disagree with what your doctor prescribes, then they question it and require a review process. You would think doctors would get really tired of having to justify everything. Since THEY are the doctor and the one seeing the patient. Of course the doctor wants you to take that drug ... he prescribed it didn't he? It drives me crazy.

Both times I had to stop taking my prescribed drugs for about a week while they decided if I was "worthy". Insanity abounds.

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TerryK
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Haley wrote:
Do you mean that everything was going through them with my insurance company even before I signed up for the program?

Yes, if your insurance company contracts with medco and from the sounds of it they probably do. Medco told me they offer the same services to the client (the insurance company) in both cases (mail in or local pharmacy billing). In reading part of their website though, it looked like they may offer more services if the patient goes through the medco pharmacy to purchase prescriptions. In other words, they may keep a closer eye on us as patients. It's hard to get a straight answer out of medco.

Call your local pharmacy and ask if your prescription billing is handled by medco. Then you'll know for sure. Of course, it's always possible that the pharmacy won't know if medco handles the billing or not but they probably do.

As Connie said, Medco would be considered the administrator. They don't need a medical release because they are acting as an arm of the insurance company or at least that's my understanding.

Terry

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JRWagner
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Is there a Walmart or Cosco in your area? Their prices are very cheap, and your insurance company should have an agreement with them...hopefully.

Good luck!

Peace, Love, and Wellness,
JRW

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burnsjw
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I wouldn't question the local pharmacy who is paying them, Medco or your ins. I think this just opens you up for questioning. Don't red flag yourself. It only takes one pharmacist at your local pharmacy to start questioning your scripts. I know of people who the local pharmacy refused to fill their scripts. some local pharmacists do not like filling certain lyme dr's scripts.
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TerryK
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burns,
Have you gone through the appeals process with your insurance company? I can often get things covered that way.

Time consuming, requires your doctor sending paperwork to the insurance company and often needs to be done every year but it is only rarely that they refuse to cover when I appeal their denial.

I have found that many insurance companies hold things up for months by constantly stating that my doctor has not sent in the paperwork. Get a copy of the paperwork and tell the insurance company that you can fax it 100's of times if necessary. Suddenly they will get your fax the first time. [cussing]
Terry

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burnsjw
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Terry, I sent you a private message. Yes , we talked to the dr. about what we should do.
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