posted
I've been on bicillin injections for a year
now. Ironically on our Washington lyme hearing
day I received a call and was told by the mail
order pharmacy for BC/BC that it was no longer
medically warranted after a year and they would
no longer fill my prescription. The pharmacist added that he would not lose his liscense to fill this.
Since when can pharmacist make medical
decisions. I was now told to appeal to see if
the decision would be reversed. Anyone already
gone down this road any have a form letter that
worked for the appeal process. Thanks for your
help.
Posts: 19 | From Phila, PA USA | Registered: Nov 2001
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TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
CALDA has a lyme times edition on insurance appeals. You can order it from their site. I'm leaving my house right now but if you have trouble finding the site, let me know and I'll find it for you.
Call your insurance company. Ask for the denial in writing and ask them to fax the forms to your doctor that he needs to fill out in order to appeal.
That will at least start the process.
The pharmacist has no place in denial of your prescription as far as I know. Sounds like he has an attitude. I'd complain after this is all taken care of.
Terry
Posts: 6286 | From Oregon | Registered: Jan 2006
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posted
About five years ago, our ins denied coverage for Bicillin injections, and in the first round of phone calls to the ins co, we were told our only alternative was a written appeal. It looked very doubtful we would ever get them to pay for the Bicillin; the rep we spoke with was pretty cold about it and insinuated we were wasting our time.
BUT...sometimes the power of prayer and persistence pays off. The following Monday, I picked up the phone and called the ins company again, not expecting much, but hoping for one last chance.
I stayed calm, friendly and polite, and asked if they could once again explain the reason for the denial. I was put on hold for quite some time while the rep who answered the phone investigated our case, and when she finally came back, she told me there might be a way the Bicillin could be covered under a different part of our insurance plan.
After another long hold, I was speaking with a supervisor who told me they would provide the coverage after all; it just needed to be processed differently, and the Bicillin would be on its way within 24 hours.
I have no magic formula to give you, no specific method to deal with this type of situation,
I write you this just to let you know that sometimes some friendly persistence can pay off.
Don't give up without a fight, but before you start fighting, consider trying some friendly persuasion with them to reconsider your case. Sometimes it works.
I hope it works for you.
Posts: 962 | From Charleston | Registered: Jan 2002
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posted
For some reason, injectables are covered under the medical portion of insurance, or the RX part, or both. I have no idea why. When my Rocephin was filled, I know that I paid a lesser copay when it was processed in the medical portion, rather than under the RX portion.
Perhaps you can look into which part of your plan was paying, and see (if the doctor is still prescribing the med) if you can have it done under the alternate part.
Posts: 374 | From United States | Registered: Nov 2008
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posted
I think this is a new trick up the sleeve of the ins co. They have the pharmacists at the mail order contractor pharmacy deny the drug. Pharmacists are apparently allowed to have opinions on treatment. And I don't think this can be appealed unless you want to try a complaint to the state medical board that licensed the pharmacist.
In this way, the ins co avoids the insurance appeal process, because it is a professional opinion of a pharmacist not a denial from the ins co. Crafty, no?
This has happened to other lyme patients with other drugs, not bicillin, so IMO it is the latest rotten way they have developed to deny abx to lyme patients.
But don't let that stop you from going after the ins co. Because they are the ones who have told their contractor to do this (which no one will admit). We need to be gathering a list of people and insurance companies who are doing this.
Posts: 8430 | From Not available | Registered: Oct 2000
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