Do you have any good links I should check out or suggestions to help me with what I describe below?
Soon I will have to speak with the pharmacist about why this company is refusing to refill my antibiotic prescription(s).
I need help with talking points to overcome the objections the pharmacist will raise about the safety of long term antibiotic use and their claim there is no effectiveness documented for long-term use in treating Lyme disease.
Thanks to LD, my memory is not what it used to be so I want to try to have a written outline in front of me before the phone call.
Some weeks ago I thought I read a sample letter on this site that was written to a congressman. I thought it had some information in it I could modify. I've been doing searches for about an hour now and can't find it--no surprise, I'm not very good at this kind of thing.
I'm going to hop over to the ILADS website and see what I can find there but before I do, thought I'd ask here and check back a little later.
Thanks for your help!
Posted by granniela (Member # 17134) on :
This is a bit like talking to myself, but in case anyone else is looking ammo for rebuttals for denials this link was found in a message regarding insurance denial over on general support.
The sample letter addresses insurance company denials but I'm adapting it to address the pharmacy denial for refilling my prescription for antibiotics.
I also printed and highlighted some articles off the ILADS website so now I just need to keep my wits about me and use these rebuttals when I get the call.
Posted by sutherngrl (Member # 16270) on :
Maybe my lyme brain is confused, but why would you need to explain anything to a pharmacist? I would think it would be the insurance company that was the problem.
Posted by Lymetoo (Member # 743) on :
quote:Originally posted by sutherngrl: [QB] Maybe my lyme brain is confused, but why would you need to explain anything to a pharmacist?
I was wondering the same thing. They have no say in this.
Glad you found the link!!
Posted by granniela (Member # 17134) on :
Since you asked, here's an explanation:
I sent in a new antibiotic Rx to a mail-order pharmacy a few weeks ago and they said they could not fill it due to their review and safety concerns. I don't remember the exact wording they used but it boiled down to them saying there is no evidence of benefit from long term use of antibiotics for treatment of Lyme disease.
I raised a big stink and the result was I was allowed to fill at a retail pharmacy for the mail order price but for only one fill on those prescriptions. If I can get a refill of them it will be at the more expensive (higher cost to me and less expensive for ins. co.) retail price.
I recently requested a refill of an antibiotic I've used for awhile and they delayed then cancelled the order. They have yet to inform me why. That's the call I'm preparing for.
I don't doubt they are in cahoots with the insurance company who also sent me a letter that pointed out they can decide if a prescription is medically necessary or not. You wouldn't think the pharmacist has any say, but they sure apparently do.
I've heard from one other lymie locally encountering the same thing (same insurance company and pharmacy) but in addition for her they are hassling her over a non-Lyme related medication as well as the antibiotic she takes.
I've written my congressmen and plan to write to others I can find addresses for when I can get a coherent letter together. I'm thinking insurance commissioner, attorney general...
Suggestions are welcome regarding content or recipients.
Posted by Vermont_Lymie (Member # 9780) on :
Pharmacists cannot make medical decisions. They are not doctors, and you are not their patient.
Tell them they can call your doctor if they have any questions! Best wishes.
Posted by granniela (Member # 17134) on :
Thank you for your comment Vermont_Lymie. That's exactly what I thought when they blind sided me the first time a few weeks back.
But I've been there and done what you suggested and I'm still fighting. Yes, they did call my doctors office and I gave permission for that to happen. End result was still a denial at that pharmacy.
Not only did I point out they were making decisions regarding my care without ever seeing me clinically or reviewing my lab results, I asked for the names and license numbers of the individuals involved but have yet to receive that information from them.
In fact, they said they could only send an explanation letter to my physician, not to me!!!!!
I fired back my rationale why they owed me, the insured, a response why my benefit was being denied and all I got was a generic form back. It said they were returning my prescriptions orders because of "reasons previously discussed."
Guess why I now own a digital voice recorder. They keep coming up with a bunch of malarkey (sp?) for why they can not e-mail me instead of calling. FYI there are state laws that govern recording calls so I ask for consent to record when they call.
I figure if it is happening to me with one of the largest health insurance companies, it won't be long before it's happening to more Lymies.
Prepare yourselves is my unsolicited advice. Read your ins benefit brochure on prescription benefits. Check out the sample letter on the Calda link I referred to above for talking points, and start printing off articles on evidence--the ILADS website is the best I've found for that so far.
The old saying is that advice is usually worth what it cost you...but seriously think about it. I was woefully unprepared for the first battle.
I may just be among the first of many that will have to fight the pharmacies from padding their profit margin by increasing my share in the cost of care. You can bet the insurance company is in support of that!
Time to go refresh my memory on what I want to say next time...
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Here's the link I was looking for: http://www.lymedisease.org/resources/insurance.html![[Mad]](mad.gif)
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