About 2 yrs. ago I was having trouble with my mom’s AARP/Medicare Complete insured through United Healthcare. I mother has Autoimmune Hepatitis (Inflammation in the liver that occurs when the immune system attacks the liver) and Primary Biliary Cirrhosis (An autoimmune disease that causes progressive destruction of the bile ducts). Her liver doctor proscribed her Mycophenolate (Cellcept) but insurance denied to pay for this $800+ a month medication. The pharmacy sent in an appeal to the insurance and her liver doctor sent in numerous appeals only to be denied again. This is the letter the insurance sent to her doctor:
Dear Ms. Brady: (mom’s doctor)
We received your request for an appeal on July 01, 2015. Thank you for bringing this to our attention. …show more content…
Mofetil A medical doctor carefully reviewed all the information for your appeal. The review is included blow.
This is what we decided:
We decided that our original decision to refuse coverage was correct. Our decision is based on:
• Medicare allows us to cover a drug only when it is a Part D drug. A Part D drug is one that is used for a “medically accepted indication.” Medicare says a “medically accepted indication” is a use that is approved by the FDA or a use that is listed in at least one of the following: AHFS-DI, or DrugDex. Mycophenolate Mofetil is not FDA approved for: autoimmune hepatitis. In addition, this condition is not one of the uses for the drug listed in AHFS-DI or DrugDex. When used for the described condition, this drug is not a Medicare Part D drug. Coverage cannot be made under the Medicare Part D benefit. The denial is correct.
• You can find this guidance in the Evidence of Coverage in the section titled “Using the plan’s coverage for your Part D prescription drugs”.
My mom’s doctor said she doesn’t understand why the insurance wouldn’t cover it because she prescribes it to her other
Dear Ms. Brady: (mom’s doctor)
We received your request for an appeal on July 01, 2015. Thank you for bringing this to our attention. …show more content…
Mofetil A medical doctor carefully reviewed all the information for your appeal. The review is included blow.
This is what we decided:
We decided that our original decision to refuse coverage was correct. Our decision is based on:
• Medicare allows us to cover a drug only when it is a Part D drug. A Part D drug is one that is used for a “medically accepted indication.” Medicare says a “medically accepted indication” is a use that is approved by the FDA or a use that is listed in at least one of the following: AHFS-DI, or DrugDex. Mycophenolate Mofetil is not FDA approved for: autoimmune hepatitis. In addition, this condition is not one of the uses for the drug listed in AHFS-DI or DrugDex. When used for the described condition, this drug is not a Medicare Part D drug. Coverage cannot be made under the Medicare Part D benefit. The denial is correct.
• You can find this guidance in the Evidence of Coverage in the section titled “Using the plan’s coverage for your Part D prescription drugs”.
My mom’s doctor said she doesn’t understand why the insurance wouldn’t cover it because she prescribes it to her other