Pharmacy denied long-term abx

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pjbat
Regular Member


Date Joined Dec 2007
Total Posts : 119
   Posted 12/4/2008 4:42 PM (GMT -7)   
I'm wondering if anyone else has experienced this... My husband and I both have Lyme disease and are going through a mail order pharmacy for our abx since beginning treatment in March, 2008. It seems as though they must have my husband's account red-flagged as they have begun denying his prescription renewals - so far for zithromax and nystatin. Early on they denied his Mepron order but finally came through on that one. They called to discuss this with him and told him they cannot renew the prescriptions since CDC guidelines do not support long-term abx use (implication being that chronic Lyme disease does not exist). When my husband reminded the guy his doctor (LLMD) was prescribing these medications, he was told there is no such thing as a doctor who specializes in Lyme disease.
 
As much as we'd like to really fight this, we're concerned they may just start doing the same with me - so far, they have not blinked an eye at my renewals. We should be able to go through another pharmacy but it will be much more expensive. Unbelievable and so maddening! mad
 


lillimul
Regular Member


Date Joined Jul 2008
Total Posts : 104
   Posted 12/4/2008 6:26 PM (GMT -7)   
My husband and I both have had lyme disease also, though I just completed 7 months of abx and caught it fairly early and have been off abx for a month now. My husband has been ill for years. The problem is probably with your insurance company, not the pharmacy. When our scripts have been denied, the pharmacy calls our doctor and or insurance company and they have worked it out so far(knock on wood) to authorize them.
My husband's IV rocephin however was just denied after 28 days- and we're worried that they(insurance) may start denying other meds(including his mepron). We're not going through a mail order pharmacy though- but the problem is probably with the insurance co. Has the insurance company called your doctor?

studeski
Regular Member


Date Joined Dec 2007
Total Posts : 62
   Posted 12/4/2008 7:09 PM (GMT -7)   
I don't have an answer for this but I don't know if the CDC has guidelines. Their site points to the IDSA guidelines. And we know what they are worth.

IDSA guidelines remember they are voluntary:

*

These guidelines were developed and issued on behalf of the Infectious Diseases Society of America.
*

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Martha's Vineyard
Veteran Member


Date Joined Jul 2008
Total Posts : 1119
   Posted 12/4/2008 7:19 PM (GMT -7)   
Studeski,
That is awful! I am so sorry. That makes me mad a hell!
I mean you have a Dr. trying to treat a sick patient and the insurance company does not want to cover you. And they can deny
you because of certain doctors...yes I am saying their names. They can sue me. [Post edited: But HealingWell doesn't want to be sued!! No flaming or attacking members or non-members, as stated in the forum rules.]
Please, we need the media.
They tell the CDC how to set their test, awfully, it would not pick up lyme in your blood if you were covered in ticks.
And so there fore you are not sick. And so therefore you do not need any expenisve meds that are actually going to take money
out of the big boys pockets who have to see a profit with their sotcks in the insurance BUSSINESS.
hey...know anyone who lives on the boarder of mexico? think you can buy it over thre counter there.

Post Edited By Moderator (alfers) : 12/4/2008 8:10:49 PM (GMT-7)


Martha's Vineyard
Veteran Member


Date Joined Jul 2008
Total Posts : 1119
   Posted 12/4/2008 7:21 PM (GMT -7)   
The Blue Cross Blue Shield actually sued a Dr. for over 100 million dollars because he was treating Lyme patients with abx.
It is dirty out there. There is a witch hunt out there.
2004 in Martha's Vineyard me and my two daughters then 11 mos and 6 all got Lyme Disease. This was only known to us because we found the tiny ticks on us and we got very ill. My dog also got lyme and he went lame.
We have fought it for 4 years to no avail.
We all got it again this summer is Texas.
I am now in treatment in Scottsdale Arizona at Envita.

"The eyes cannot see for for what the mind does not know."


sojourner
Veteran Member


Date Joined Apr 2006
Total Posts : 1173
   Posted 12/4/2008 9:11 PM (GMT -7)   
When a patient is first denied a claim or prescripton refill, it is at the lowest level of the totem pole.  A challenge is always merited when the diagnosis has been differential and affirmed by a trained specialist.  Always appeal.  This will actually protect the one who has not yet been denied once precedence is established.
 
First, your doctor needs to be involved and contact your prescription provider, either by phone or with a letter.
 
Second, you need to provide your insurance company with the following:
It is of the utmost to provide credible science and/or articles that have references to studies when challenging.
 
http://www.beyondthecure.org/future/insurance/survivor/issues.html - contact your state's insurance commissioner. 
http://www.patientadvocate.org/resources.php?p=178 - Insurance commissioners by state
 
The code of ethic if an unjust denial is determined by the insurance company is that the insurance carrier is considered to be acting in 'bad faith'.  This is a legal term that would be applied in an appeal letter.
 
Taking these steps should bring about a resolution in your favor.
Hope this helps.
Blessings,
Sojourner (Diana)
 

"God loves with a great love the man whose heart is bursting with a passion for the impossible." ~booth

www.stylebyheatherrose.com -click "Lyme testimony" and "Lyme Disease" for a panoramic view of the truth.  Lyme disease - coming to a tick near you!


pjbat
Regular Member


Date Joined Dec 2007
Total Posts : 119
   Posted 12/5/2008 7:16 PM (GMT -7)   
I think it probably is the insurance company that is denying the coverage and not just the pharmacy, and I agree that is who we need to contact. I appreciate the feedback, I think we just need to take a few deep breaths and tackle this again. One of the problems has been the communication between the pharmacy company and our doctor. Our doctor's office is a little difficult to get in contact with and does not like to be in the middle of insurance issues. Sojourner, thanks for the information and links, we'll take a look at this and pursue. I'll let you all know of any progress.
 

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