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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


Please consider becoming a much needed sustaining member of 
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Your contribution will eliminate this header from your IP mail

> 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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