Insurance coverage

In the United States, private insurance coverage varies widely. Federally-funded and state-funded plans also vary in their coverage. Unfortunately for Marshall ProtocolA curative medical treatment for chronic inflammatory disease. Based on the Marshall Pathogenesis. (MP) patients, insurance companies have a strong motivation to refuse coverage: an economic one.

It has been the experience of MP patients that getting full coverage for Benicar three to four times daily has posed the most serious problem. Whenever calling an insurance company, patients should expect excellent service but not be too surprised when they do not get it. This can be very frustrating. In fighting a claim denial, patients should be persistent, professional, and well-organized.

In time, as more studies are published about the Marshall Protocol, insurance companies' denial of Benicar promises to be a thing of the past.

There is no substitute for olmesartan (Benicar)Medication taken regularly by patients on the Marshall Protocol for its ability to activate the Vitamin D Receptor.. Be sure to have an adequate supply in case coverage is denied.

Summary of insurance coverage

Expense Covered by insurance?
Doctors visits Typically, yes. Covered by insurance with the usual deductible and co-pay stipulations. These visits do not need to be frequent. Many doctors encourage their patients to get routine information and support from our websites. Other routine labwork to monitor organ function is usually covered by insurance.
Olmesartan (Benicar) Varies
Test of vitamin D metabolites Typically, yes. For full coverage, be sure to use the appropriate codes.
Other labwork Typically, yes.
Marshall Protocol antibiotics Typically, yes. Antibiotics can be ordered as a generic or not, and at the standard dosage and schedule without question to maximize one's insurance benefit. Because they are taken at a lower dose and pulsed, they will last a much longer time. The doctor's instructions can simply say “take as directed.”
NoIRSpecial sunglasses worn by Marshall Protocol patients to block light. or other recommended sunglasses Typically, no.

Patients have a right to be covered for the Marshall Protocol

Thousands of patients have used the Marshall Protocol. It has an excellent record both in terms of safety and efficacy, as evidenced by the numerous patients reporting symptom remission.

Insurers who deny coverage for Benicar are denying medical care, a care that has the very real potential to cure a patient's disease. It is worth fighting for the full insurance benefit because Benicar is a fairly expensive medication. Brand-name Benicar can be $1,200 or more a year – although the generic equivalent can be purchased for a great deal less.

What may be especially frustrating about the denial of Benicar is how it is much cheaper than any number of palliative medications that make the disease worse: anti-TNF-alphaA cytokine critical for effective immune surveillance and is required for proper proliferation and function of immune cells. drugs, interferon, corticosteroidsA first-line treatment for a number of diseases. Corticosteroids work by slowing the innate immune response. This provides some patients with temporary symptom palliation but exacerbates the disease over the long-term by allowing chronic pathogens to proliferate., etc. One's insurance company may be too short-sighted to see this, but going on the MP will reduce the cost of medical care over the long-term.

Doctors have a right to exercise their judgment

According to a statement by the FDA, “Good medical practice and the best interests of the patient require that physicians use legally available drugs, biologics and devices according to their best knowledge and judgment.”

It is the doctor who has the license to practice medicine – not the insurance company! With the consent of the patient, it is the doctor's right and responsibility to decide which therapies a patient receives. If a doctor is williing to accept responsibility for the way he or she practices medicine, an insurance company has no right to interfere.

Tips for working with an insurance company

  • Keep a detailed log of calls – Patients should note: the first and last name of any customer service representatives (CSR); the date of time of the call; and, any case numbers assigned. Patients who feel it might help should ask for a personal extension of a helpful CSR.
  • Be persistent – Some insurers make the appeal process as difficult as possible – long waits on the phone, clueless sales representatives, referrals to the wrong department, misinformation, lost faxed forms, etc. – so it may take some persistence on the patient's part as well as that of that one's doctor.
  • Politely go on the offensive – Emphasize the prescribing doctors' right to do what is best for their patient. If an insurance company representative says that Benicar is unsafe in the doses prescribed by the MP, ask for proof.
  • Avoid certain language that has a history of eliciting defensiveness
    • Experimental – Some insurers consciously do not cover medications considered experimental, so it is important not to use that word.
    • Off-label use – In the context of the MP, referring Benicar use as off-label is ill-advised – even though off-label use of medications is expressly permitted and encouraged by the FDA.
  • If accurate, a diagnosis of hypertension is helpful – If a patient fits the criteria for diagnosis of hypertension, the FDA-approved indication for Benicar, and if the patient's blood pressure does not respond adequately to one 40mg tablet a day, then the package insert's prescribing instructions' “Dosage and Administration” saying “dosage must be individualized.”

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Appealing a denial for Benicar

Sometimes an insurance company will balk at covering higher than customary doses of Benicar. If so, patients may need to challenge that decision and/or file an appeal, a process which can take several weeks or months. All insurers have an appeal process for claims that are denied. The following steps are typical in an appeal:

  1. The initial problem may be with the pharmacy, which sometimes has upper limits on the dose and frequency of certain medications. Sometimes this will need to be overridden by one's insurance company.
  2. Other times all that is needed to override an initial denial is a phone call from the doctor's office verifying that he or she has determined that the prescribed dose and medication are exactly according to his or her wishes. Some insurance companies require that a doctor fill out a form, sign it, and fax it back to the insurer to obtain an override. This override is often good for one year.
  3. If a doctor override is not sufficient, accept the standard amount of pills until the insurance company approves the increased dosage. Patients can either start taking Benicar at the prescribed dose right away and hope that an eventual appeal will be successful in a short time frame or wait until the full prescription is filled. For patients who run out of Benicar before being able to fill the remainder of the prescription, it is safe to stop Benicar abruptly early in the treatment and start it again when the full prescription is approved.
  4. Contact the insurance company and ask if their doctors produced a letter of medical necessity would allow for full coverage of Benicar (see below).
  5. Ask for an explanation of the decision and the specific rationale why the claim was denied. The reason given will dictate the peer-reviewed papers and other materials presented to the insurance company.
  6. Indicate a desire to begin the appeals process. Ask for an explanation of the appeals process and the steps required.
  7. If appropriate, gather materials and studies which support the safety and efficacy of high doses of Benicar. Some insurance companies require that you send them peer-reviewed studies which support use of Benicar at three or four times daily.

Materials to present an insurer

Most insurance companies will only accepted peer-reviewed papers demonstrating the safety or efficacy of Benicar. For information on Benicar's safety, consult the relevant article. There are a number of studies mentioned. Two good papers to refer to are Schwocho and Brunner.

Efficacy of Benicar has been described in various conditions by a forthcoming peer-reviewed paper in Annals of the New York Academy of Sciences. That paper will be available in the Fall of 2009. For a preprint – or for any other paper – ask on the MP study site.

Letters to present to an insurance company

Generally speaking, most Marshall ProtocolA curative medical treatment for chronic inflammatory disease. Based on the Marshall Pathogenesis. (MP) patients find that the MP antibiotics are covered by their health insurance. Sometimes, however, an insurance company will balk at covering the higher-than-usual dosage of olmesartan (Benicar)Medication taken regularly by patients on the Marshall Protocol for its ability to activate the Vitamin D Receptor.. Patients who are denied coverage for the dose of olmesartan (Benicar) that the MP requires have the right to appeal that decision.

An MP patient's physician may need to write a “Letter of Medical Necessity” to the insurance company in order to help the patient obtain needed coverage. Below are form letters that a patient or his/her physician may find convenient to use. These letters contain information that has helped some MP patients obtain insurance coverage for the full dose of olmesartan (Benicar).

Patients may want to include printouts of Knowledge Base articles that discuss the safety and efficacy of olmesartan (Benicar).

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Ordering olmesartan (Benicar)

There is no substitute for olmesartan (Benicar). Patients buy or obtain olmesartan in a number of ways. If their insurance covers the medication, they may fill the prescription at a local pharmacy or via their insurance carrier's mail order service. Others obtain Benicar or its generic equivalent through mail order, often ordering three months' supply at a time.

There is no evidence to suggest that the generic version of Benicar, such as Olmecip, is inferior. Patients who like to be cautious, however, may prefer the brand name drug, which tends to be about five times more expensive for patients who are paying out of pocket.

Patients are warned not to order Benicar HCT, which contains a diuretic.

For those who cannot afford the cost of olmesartan, certain patient assistance programs are available.

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