I'd be interested to know how this worked. My daughter's medication was just denied yesterday. She has an oral aversion and they will only.cober the medication in the pill form. Our doctor filed a request, which was denied. Their response was the the insured party could file an appeal. Anything your wife said would be helpful! Thanks!
Tell your doctor to test you for h. pylori.
Wouldn't you be appealing to Atena directly ?
Not exactly. They might cover it, but just because the Dr. says you need that specific med, it could still be denied. I’ve actually talked to my Dr about this. They can recommend to insurance that you need that specific med, there’s no guarantee insurance will go along with it. They don’t have to. I currently take a med that there is no generic option for. Years ago I used to take another medication that was much cheaper, that one stopped working and my Dr put me on the new one. I’m waiting for the hammer to drop and insurance to say they’re not covering it anymore. It’s $1100.00 for 90 pills. The generic I used to take was $60 for 90 pills. These insurance companies are so shady. They actually tried to go behind my back and contact another one of my doctors, that has nothing to do with this med, to see if I can go back to the cheaper medication. Insurance companies are the biggest pieces of sheet. No problem taking anyone’s money.
I was told differently. I spoke to a rep at Atena and was told "The doctor needs to write the script for the name brand and must specify that only the brand name is to be used". After that the insurance company will most likely require a letter from the doctor stating why he is writing it for the brand name and no generic. After that appeal process the drug will be approved.
Interesting. I haven’t gotten to that point, so maybe my Dr. was just telling me that, just to warn me about what could happen. I think what also factors in, whether a similar medication is close enough. The expensive one I take is exactly like the cheap one, except is delayed release. Throughout the day, small amounts are released. Also a stomach med like the OP.
A lot of the times the generic is pretty much identical to the brand name with maybe a changed molecule. So ideally the generic should work just as good as the brand name. However if that’s not the case that’s when you would have to appeal for the brand name.
The active ingredients of a generic are the same but the exact formulation can vary. Sometimes you can notice a difference. And different people will react differently.
Yea I remember getting a letter telling me they were going to change my drug and that I needed to contact my doctor. I threw the letter in the trash and nothing ever came of it.
My prescription card was through a company owned by Merck Medco so they tried to push their own drugs.
Yeah it’s really shady. Like I said they went around me, contacted my PCP to try to get me off the expensive med. My PCP isnt even the one that put me on the med. Then when I called them out on it, they tried to tell me, that my Dr. was the one that contacted them, and told them that I should be put on the cheaper medication. Like out of the friend’n blue, my Dr is going to call them, and tell them to put me on something cheaper. My PCP originally agreed to it. I got an email stating that my medication had changed. It was all straightened out, but I went off on my PCP. Told him don’t ever get involved in that medication ever again. Take that medication out of your system. Because any Dr you see knows what meds you’re on. It’s like a central system that’s all archived.
Keep appealing. You have to include the fact that there is not another alternative.
