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» LymeNet Flash » Questions and Discussion » Medical Questions » Medications, Insurance, Consistancy

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Author Topic: Medications, Insurance, Consistancy
bethanie70
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Member # 5439

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My dr is ready to start me on Mepron and Zithromax for Babs. As I'm sure a lot of people do, I'm having trouble getting both covered. After a fight, I finally got the Mepron covered, but only for 3 weeks when he wants me to take it for 4 months. The Zithromax, I got only 6 tabs and am fighting for more (4 months needed as well). I am anxious to get started because I'm so sick and my kids need me even a little better. I'm afraid to start though in case I don't get the Mepron covered in time before I run out three weeks into it. I'm fighting, but there's no guarantee when or if it will go through. It seems like most people say about Babesia that it's dangerous to go off and on. That complete consistancy is required to avoid it building up immunity. I have been leaving messages for my dr without reply so far. Thought I'd see what people here think. Thanks!!!
Take care,
Beth

Posts: 72 | From California | Registered: Mar 2004  |  IP: Logged | Report this post to a Moderator
hwlatin
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Member # 4123

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Insurance is really complex. First thing you need to know is who has the financial responsibility. Is it your company or the insurance company.

If the company is just using the insurance company as a payor/administrator, you need to approach your companies human resources and discuss the situation with them, they can and in most cases will make exceptions.

If your company has purchased the plan from an insurance company, my suggestion is to bypass all customer service and go directly to the Office of the President of the insurance company. THey have a staff there that I think is better equiped to help than customer service.

Go onto the internet and search for the insurance companies corporate number and when you get the operator ask for the Office of the President. Do not be afraid to voice your concerns. I would do this first even if you get a denial, before you go through the ERISA Appeals Process. I have never had to file an appeal yet, have come close but have gotten everything taken care of before that was necessary through this office with three insurance companies.

Do make sure that your request is not unreasonable, and always document all of your conversations, so that you have good information behind you. I was on Mepron/Zith for a total of 12 months, 2 6 month periods, and I never had a problem getting it paid for.

If you can not get satisfaction from the Pharmacy plan they are normally subcontractors to the insurance company so go up the ladder there too. You will never get the number from customer service, that is why you have to find the corporate number out yourself. Good Luck.


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bethanie70
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Thanks for the reply and the info. The pharmacy told me that Mepron is $2700 a bottle. So I can see why four months worth would be questioned. At this point the pharmacy is working with the insurance and my dr to get it approved.

I'm just wondering if I dare start until I have it approved for the whole time. I don't want to wait though. I've been very sick for a long time and want and NEED (3 young children) to get better.


Posts: 72 | From California | Registered: Mar 2004  |  IP: Logged | Report this post to a Moderator
bethanie70
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Member # 5439

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Thanks for the reply and the info. The pharmacy told me that Mepron is $2700 a bottle. So I can see why four months worth would be questioned. At this point the pharmacy is working with the insurance and my dr to get it approved.

I'm just wondering if I dare start until I have it approved for the whole time. I don't want to wait though. I've been very sick for a long time and want and NEED (3 young children) to get better.
Take care,
Beth


Posts: 72 | From California | Registered: Mar 2004  |  IP: Logged | Report this post to a Moderator
   

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