RE: [IP] Medco
You need to appeal to Medco, however it they are big enough to split
contract they probably have an internal Plan Administrator that can help.
-----Original Message-----
From: email @ redacted
[mailto:email @ redacted] On Behalf Of Barry
Sent: Thursday, October 01, 2009 8:32 AM
To: email @ redacted
Subject: Re: [IP] Medco
My employer has contracted with BC for insurance without RX, ans directly
with
Medco for drugs. What path would I follow to file this appeal?
Barry Polner. (Atlanta)
pin:207ae9e8
"In my many years I have come to a conclusion that one useless man is a
shame,
two is a law firm, and three or more is a congress."-John Adams (1735-1826)
-----Original Message-----
From: email @ redacted
Date: Wed, 30 Sep 2009 17:11:49
To: <email @ redacted>
Subject: Re: [IP] Medco
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> In response to the folks having issues with Medco . . .
>
> (This is my personal experience only)
>
> When your company contracts with Medco for pharmacy coverage, they
> have contract limits as to how much of any particular medication they
> will cover--no matter what your doc actually prescribes. I have
> actually gotten letters from them in the past telling me that they
> will only fill up to a certain # on some of my prescriptions--period.
> As I have had chronic yeast infections For the past several years--my
> doctor usually writes a prescription for as many as 1 per week for a 3
> month period. They decided they would only fill up to the max that
> the contract covered--which was significantly less than what my
> prescription was for. In those situations, my doctor has been
> gracious enough to provide me an extra prescription script that I can
> pay cash for should I need to exceed what Medco would cover. It's not
> great by any means--but it has worked for me. Luckily, this is a
> fairly inexpensive medication--otherwise, I would be in big trouble.
>
> Lona
> .
Usually your use of Medco and similar pharmacy providers is through a
contract with your insurance company. In general neither you or your
company have any contractual relationship with this provider.
However, what the insurance company does is enter into a contract
with that third party provider which limits what they may dispense.
This is a "cut-out" for them. Their contract with your employeer, and
hence with you, does not contain limits on what may be provided
usually because this would violate state insurance rules governing
health coverage providers. So....
Unless your contract of insurance SPECIFICALLY says that there are
limits to your coverage and the limits are spelled out for each item
directly in YOUR COPY of the contract of insurance, the ins.co. is
contractually bound to provide you with what the doctor orders as
long as it is in the pharmacy guide or is not experimental or some
other weird thing like that.
To get around this problem, contact your insurance company directly
and ask for the pharmacy co-ordinator for the ins.co. Don't let them
fob you off to Medco which is what they will try to do.. Insist that
the prescreption be filled in full and when they refuse (they will)
ask them to point out where in your contract of insurance it says
there is a limitation. At this point you will need to appeal their
negative decision.... this is routine. You will need to then appeal
the refusal of the first repeal since there are two levels of
appeals, remembering to ask politely each time for them to point out
to you "where in your copy of the contract of insurance there is a
limitation on what the doctor prescribes". At this point I expect
your will be successful, however, if you are not, contact your state
insurance commissioner and file a complaint about breach of contract
by your health insurance carrier. Specifically: that they agreed in
their contract of insurance to provide medications prescribed by your
physician and they have failed to do so after two levels of appeal,
further that you believe that this practice is widespread and that
you would like two things:
1) your medications as provided for in your contract of insurance
2) an investigation into the abusive practices of your health
insurance provider.
Michael
.
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