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 Protocol (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). Be sure to have an adequate supply in case coverage is denied.

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.

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.

• 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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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.

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.

• Schwocho LR, Masonson HN. Pharmacokinetics of CS-866, a new angiotensin II receptor blocker, in healthy subjects. J Clin Pharmacol. 2001 May;41(5):515-27. doi: 10.1177/00912700122010393.
  [PMID: 11361048] [DOI: 10.1177/00912700122010393]
• Brunner HR. Clinical efficacy and tolerability of olmesartan. Clin Ther. 2004;26 Suppl A:A28-32. doi: 10.1016/s0149-2918(04)90143-9.
  [PMID: 15291377] [DOI: 10.1016/s0149-2918(04)90143-9]

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.

• Tips To Effectively Battle Your Insurance Company