Humana - Dr. Silvester Medical Director For My Dr. Prescribed Nexium was rejected by Dr. Silvester Barczak Medical Director Humana Louisville Kentucky

I'm angry because this guy's got a hole in his stomach, and Humana pays a doctor sitting at a desk with a rubber stamp 6 figures to deny a $70/month treatment for it.

I didn't say 80 mg of Nexium was unsafe. I just said this person's drug formulary said a specific dosage had to be authorized by the doctor very easily.  

Wow, you have some anger issues.

Dosages up to and including 80 mg per day are considered safe by the FDA.

Without taking sides here, I am the law is actually correct. Alot of drugs have quantity limitations on them, usually for safety reasons. Those quantity limits can be overridden very easily if the doctor will sign off on the dosage. This form can be easily obtained by the doctor by calling 877-259-0273 and one will be faxed to them.

And denied. That is why OP filed ripoff report.

It costs LESS to fill script than to pay doctor to deny.

The excuse: Prescription med is the "same" as over the counter med.

Hence the boring chemistry digression.

Humana should stop denying adequate treatment for serious medical conditions requiring prescription medications. They should stop throwing our money away. The Humana doctor is careless and a waste of money.

This is an example of a "ripoff".

This post has gotten huge! Why are people arguing chemistry when the persons drug list only covers 40 milligrams of this? No one cares who knows more about what is in a pill.

In reference to this particular post, the administative physician is a waste of money. It would be cheaper to give this guy Nexium than to pay these doctors to deny the prescription.

This current system is run by lobbyists, negotiators and shareholders.

Why not let the American people and the free market run it? Crummy doctors would not be able to run "medicare" mills, and decent doctors could make a good living delivering quality care without the meddling administrators and lobbyist taking their "cut". Our money would go to the healthcare industry.

If you want insurance and health care to be non-profit, who will run it?

I know I wouldn't open an insurance company if I couldn't make a profit.

I think I'm done with this thread. Thanks for the inane arguement, I hope someone listens to your insane rant about managed care. Until then, I will enjoy one of the world's best health care systems.

Go right ahead.

Medicare is wasteful. We now have too many recipients enrolled in medicare "HMO" and "PMO", and have managed care waste. Also, we now have "prescription drug coverage" also fraught with managed care waste.

Get rid of managed care. We don't want anymore lobbyists and shareholders. Non- profit is better. Trying to make a buck off a doctor or a patient is wasteful and hazardous to your health. Healthcare is already a "business" with "profits" etc... It is best left in the hands of healthcare professionals. You want profit to be wasted on lobbyists, sleazy bankers and crooked congresspeople?

I'm done with that. I hope managed care gets eliminated.

That costs are so high. No doctor in this country can charge a lower price than medicare. The government sets what a procedure costs with medicare. There's no competition because doctors and insurance companies CAN'T go lower than medicare.

If I was a doctor, and I decided to open a practice, and only charge people say 30$ to see me, I would not be allowed to do this because that price is less than medicare. That's whats broken about the system.

As for people getting rich off insurance, well DUH, they are private buisnesses. Who would run an insurance company if they couldn't turn a profit? Who would run ANY buisness if they couldn't turn a profit?

If you don't have insurance in this country, you aren't trying very hard. With the exception of people deemed "uninsurable" you can get insurance cheaply from almost any employer in this country. If you want insurance, make that a priority when selecting a job. I got insurance during college working part time at a gas station for barely above minimum wage. It wasn't great insurance, but it beat not having insurance.

Getting medical insurance and medical care is not a right in this country. Its something that a responsible adult takes care of for themselves and their families.

The costs will go down- It is a business.

Stop the public trading of our healthcare dollar, and we would get more healthcare.

Managed care IS broken. There are 40-50 million uninsured Americans. Those insured are just fine, and don't want any other choices, I guess.

I kind of trust the free market of our democracy more than Wall St. and the NYSE, I guess.

Sorry you think managed care has done the job. I think our $640 billion could go to much better use than Bernie Madoff schemes, and shareholder profits.

As for Medicare, I think it is a separate issue. I don't want any government managing my healthcare dollar- especially a lobbyist for a large corporation publicly traded on the NYSE, and receiving $25 billion economic stimulus. You want to use Medicare as the "gold standard"? That is a pretty low standard.

I think our country is very innovative and technologically advanced, and can do much better than medicare.

You want the government out of managed care and put us back in to just plain insurance. Where the company just has to pay for anything a doctor tells them to pay for? No oversight?

Oh wait... to get RID of managed care you would have to get the government involved. They could remove their restrictions but then they would have to make new restrictions.

I'll agree that it needs to be overhauled. I don't think its broken right now though. The only thing driving up cost in the medical field is medicare.

The free market provides plenty of low cost insurance plans to fit everyone's needs.

For years we did just fine without "managed care".

We had insurance. We did fine. We did not have "national health care"!!!

WTF is wrong with everybody? Why do we need "managed care"? Is the only alternative to "managed care" "national health care"? OF COURSE NOT!!!!

Eliminate the middle manager. Eliminate the NYSE listing. Eliminate the congressional involvement. Eliminate the lobbyists. Cost of care will plummet, guaranteed! Eliminate "administrative physician".

The free market will determine the cost, instead of the NYSE.

However, government has to regulate the industry wisely, or healthcare will continue to be the fiasco that it already is.

We currently have no choices, except for managed care. Unless you are over 65, or disabled, or eligible for medicaid. Just give us some normal insurance companies, for once. Pay the doctors who actually treat the clients (not just the doctors in the managed care "club"). Forget about "the shareholders". Get rid of lobbyists (lobbyists for healthcare corporations should be freaking illegal, but it isn't).

I could list a thousand other ways to correct the fiasco managed care has caused, but I think the best way at the moment is to COMPLAIN! Don't let these crooks rip us off anymore. Do not let them deny our care anymore. Put up a fight.

Ever wonder why Humana has no complaints department?

After trying various proton pump inhibitors and then reading about the medicines and figuring out I was wasting money on nexium when prilosec was the exact same medicine I stopped taking it.

As for managed care, okay so you want to rip on it. That's fine, it isn't perfect. *I* am perfectly happy with united health care for my medical needs, but a lot of people aren't.

So what's your solution then?

No one is forcing anyone to be part of managed care. There are options available to you. Do you want to see us go to a government care system? DO you want us to have managed care removed from this country?

You complain, but what is the solution?

You asked for it:
By configuration: D- and L-

An optical isomer can be named by the spatial configuration of its atoms. The D/L system does this by relating the molecule to glyceraldehyde. Glyceraldehyde is chiral itself, and its two isomers are labeled D and L (typically typeset in small caps in published work). Certain chemical manipulations can be performed on glyceraldehyde without affecting its configuration, and its historical use for this purpose (possibly combined with its convenience as one of the smallest commonly used chiral molecules) has resulted in its use for nomenclature. In this system, compounds are named by analogy to glyceraldehyde, which, in general, produces unambiguous designations, but is easiest to see in the small biomolecules similar to glyceraldehyde. One example is the amino acid alanine, which has two optical isomers, and they are labeled according to which isomer of glyceraldehyde they come from. On the other hand, glycine, the amino acid derived from glyceraldehyde, has no optical activity, as it is not chiral (achiral). Alanine, however, is chiral.

The D/L labeling is unrelated to (+)/(-); it does not indicate which enantiomer is dextrorotatory and which is levorotatory. Rather, it says that the compound's stereochemistry is related to that of the dextrorotatory or levorotatory enantiomer of glyceraldehydethe dextrorotatory isomer of glyceraldehyde is, in fact, the D isomer. Nine of the nineteen L-amino acids commonly found in proteins are dextrorotatory (at a wavelength of 589 nm), and D-fructose is also referred to as levulose because it is levorotatory.

A rule of thumb for determining the D/L isomeric form of an amino acid is the "CORN" rule. The groups:

COOH, R, NH2 and H (where R is a variant carbon chain)

are arranged around the chiral center carbon atom. Sighting with the hydrogen atom away from the viewer, if these groups are arranged clockwise around the carbon atom, then it is the D-form. If counter-clockwise, it is the L-form.

Who cares, anyway?

The problem posted by OP is not just with Humana. It is managed care. The managed care companies waste our money by paying physicians to "deny" needed treatment with no medical basis. The price and "quantity limits" are pre determined before the claim. There is no organic chemistry involved. Worse yet, no medical knowledge is used, either. Humana's formulary is written by Humana regional managers, and thus the formulary varies by region. That is because Humana's businesspeople "wheel and deal" with local governments and big pharma before writing the policies and formularies. "Medical director" is just to give illusion of legitimacy. The "doctor" for Humana just stamps his/her name on the denial. It is a waste of money. More of a waste than giving OP some Nexium.

If you try to verify Humana's doctor in this case, you will find he has an MD degree. However, you will find that Dr. Barczac holds no medical license in Kentucky or Ohio. His job is to deny your medication based on formulary.

OP in this case, has exposed Humana's inability (or unwillingness) to acknowledge medical decisions based on medical fact. I would urge the administrative physicians to be much more careful with their members. Lives are at stake here.

As for Achalasia, sounds like you get your proton pump inhibitor at Walmart- you state Prilosec is the same as everything else. You need not run that through insurance.

I'm not arguing your information on amino acids, the point is that they are not enantimers. They are diasteromers.

If you see the notation S- or (S)- or (s)-, or R- or (R)- or (r)- then you are referring to an enantiomer.

if you see d-, D-, (D)-, or (d)-, OR l-, L-, (L)-, or (l)- then you are seeing the notation for a diasteromer.

A chemical can have both forms. You could have a d-chemical and discuss its R- and S- forms.

Plug: CHIRALITY in to google and read about it. Wikipedia has a nice simple entry that explains it in a way that is easy for a non-scientist to understand.

Why are you still bringing this up anyhow? I told you I was done with it and you keep bringing it up, when you clearly show no understanding of stereochemistry or isomerism.

And yes, the OP can fire humana. he is not stuck with them. He will have 6 months of out of pocket treatment for this disorder before he can get a new insurance company. You claim that nexium can be gotten cheaply, so a 6 month supply should be easy for him to get while he waits out the pre-existing condition clause for a new insurance company.

I suffer from Achalasia, look that one up, and I have switched insurance companies 4 times in the last 3 years until I found one that would give me the proper treatment.

This client is stuck with Humana, due to existence of "pre-existing condition". Any attempt to get coverage other than what OP is currently getting, will result in "non-coverage" for hole in esophagus.

I know it is hard to grasp, but I'll try again-
D- and DL-phenylalanine

The unnatural stereoisomer D-phenylalanine (DPA) can be produced by conventional organic synthesis, either as a single enantiomer or as a component of the racemic mixture. It does not participate in protein biosynthesis although it is found in proteins in small amounts - particularly aged proteins and food proteins that have been processed. The biological functions of D-amino acids remain unclear although some, such as D-phenylalanine, may have pharmacological activity.

All amino acids (except the perfectly symmetrical amino acid glycine) have enantiomers, using notation "D" and "L". I'm sorry the notation confuses you, but I did not invent it. Without the proper enantiomer for each amino acid WE DIE. Yes, enantiomers DO MAKE A DIFFERENCE. Proton pumps are activated and blocked because they are three dimensional "receptors". One enantiomer fits, one does not. However, there is no telling what the enantiomer that does not block the proton pump will do. It may cause tumors, and/or side effects.

It is currently not possible to do clinical trials to find out what harmful effects the enantiomers might have. It is completely unethical. The FDA would not allow one to do a study on how many tumors we get from the unwanted enantiomer in Prilosec. Or how many deformities or deaths we get from certain substances. Too bad. We are stuck with incomplete data. That does not mean it is all "propaganda". We have an incomplete fossil record- are you a creationist who has no belief in evolution?

Best advice- OP should get 2 identical prescriptions from his doctor for 40 mg Nexium, quantity 30. Take 1 prescription to pharmacy 'X', pay the Humana tier 2 copay, then take second prescription to a discount pharmacy (I'm quite certain that he can get 30 nexium for less than the $159.69 price tag Humana is quoting.)

You're still wrong about the chemistry, but I'll drop it.

to the OP:

Fire humana. Take your insurance money to a company that will fill your prescription.

Problem solved.

This may be confusing to you. L-tryptophan and D-tryptophan are enantiomers. they are not "Diastereomers."

Please go to (((Redacted)))

Who cares anyway?


CLICK here to see why Rip-off Report, as a matter of policy, deleted either a phone number, link or e-mail address from this Report.

So, removing the enantiomer that caused side effects of racemate IS helpful.

If I suffered from asthma, and had a cardiac problem, I would hope my doctor was smart enough to use Xopenex.

For average asthma sufferer, perhaps racemic albuterol is "just fine".

I, for one, would not want to get an arrythmia. Would you?

I do not want tumors, either. That is why IN SOME SERIOUS CASES (like OP), higher dose of proton pump inhibitor needed. If OP had "gas", I would suggest over the counter remedy. This guy's got a hole in his esophagus. Why not get it right the first time instead of trying to save fifty or sixty bucks? IN THIS PARTICULAR CASE.

What the heck is wrong with y'all anyway? Is organic chemistry the topic? No. Read complaint. This guy is suffering. He is expressing his misery about the rigid limitations and impersonal treatment he gets from his insurance company. Are you all blind or something?

Performing "cookbook" medicine may be OK for some people, but the managed care docs need to be more careful with their members. We could do better with the $640 billion. I would urge managed care to actually take care of its members, but that is obviously too much to ask.

Therefore, I would advise that OP get 2 identical prescriptions from his doctor for 40 mg Nexium, quantity 30. Take 1 prescription to pharmacy "X", pay the Humana tier 2 copay, then take second prescription to a discount pharmacy (I'm quite certain that he can get 30 nexium for less than the $159.69 price tag Humana is quoting.)

With the BORING biochemistry when you do.

As for your previous statement, Xopenex is the same as albuterol. You will get the same relief as an asthma patient (which I am) with either one. The Xopenex has less side effects from better isolation of the chemical but no greater function.

The use of levosalbutamol (levalbuterol) over the more traditionally used racemic salbutamol (albuterol) is controversial among health care professionals. That using levosalbutamol instead of salbutamol produces less direct effect on 1-adrenergic receptors and/or fewer cardiac side effects has been suggested, but not consistently demonstrated by long term, well-designed clinical trials.

There are differing opinions on whether there is sufficient therapeutic benefit to using levalbuterol that outweighs the 5-10 times higher price tag. In general, it appears that if a clinician and patient feel that a low dose of racemic mixture is causing undesirable side effects, levalbuterol may be a viable alternative.

This is yet another example, like nexium, of a pharmaceutical company attempting to maximize profits at the expense of the masses.

As for humana, I stick to my guns that they have a right to challenge prescriptions that seem unnecessary. Like this 80mg nexium.

I'm sure you will respond again saying I don't know anything about chemistry and to shut up, followed by another insane rant about humana. I grow weary of this, I believe I have demonstrated my point well enough to anyone that passes by.

L- and D- are still using in IUPAC nomenclature. They are not an old labelling method.
They stand for Levrorotary and Dextrorotary. They have to do with the way the substituant functional groups are arranged on a molecule.

Just for you, a simple flow chart for Isomers.

http://en.wikipedia.org/wiki/File:Isomerism.png

if you would just do a little research you would plainly see that d-Tryptophan and l-Trypophan are not enantiomers, but diastereomers. While Nexium and Prolosec are enantomers.

You arguement changes nothing. Prilosec and Nexium are the same drug. AstraZeneca pulled a fast one on the public so that they could make billions off us. Why aren't you ranting about them ripping us off?

L- and D- are still using in IUPAC nomenclature. They are not an old labelling method.
They stand for Levrorotary and Dextrorotary. They have to do with the way the substituant functional groups are arranged on a molecule.

Just for you, a simple flow chart for Isomers.

http://en.wikipedia.org/wiki/File:Isomerism.png

if you would just do a little research you would plainly see that d-Tryptophan and l-Trypophan are not enantiomers, but diastereomers. While Nexium and Prolosec are enantomers.

You arguement changes nothing. Prilosec and Nexium are the same drug. AstraZeneca pulled a fast one on the public so that they could make billions off us. Why aren't you ranting about them ripping us off?

L- tryptophan and D- tryptophan ARE enantiomers. They are not "Diasteromers".

The "D" and "L" nomenclature is historical, and applies to all enatiomers of amino acids, a family of molecules which includes tryptophan.

L- tryptophan and D- tryptophan ARE enantiomers. They are not "Diasteromers".

The "D" and "L" nomenclature is historical, and applies to all enatiomers of amino acids, a family of molecules which includes tryptophan.

L- tryptophan and D- tryptophan ARE enantiomers. They are not "Diasteromers".

The "D" and "L" nomenclature is historical, and applies to all enatiomers of amino acids, a family of molecules which includes tryptophan.

L- tryptophan and D- tryptophan ARE enantiomers. They are not "Diasteromers".

The "D" and "L" nomenclature is historical, and applies to all enatiomers of amino acids, a family of molecules which includes tryptophan.

I no longer trust your opinion.

In a previous post, you stated that "Enantiomers have, when present in a symmetric environment, identical chemical and physical properties except for their ability to rotate plane-polarized light."

Maybe in a test tube, but not your body.

Are you still recommending that ALL HUMANA CLIENTS WHO HAVE ASTHMA stop their Xopenex, and begin racemic Albuterol, because the enantiomer is INERT????????????

So post this statement, and I will believe you. Stop giving us FAKE INFORMATION. I'm sick of studying this BORING biochemistry! It is not the issue.

If you stop bludgeoning us with this silly scientific babble, I promise I will admit most people with reflux and indigestion should take Prilosec instead of Nexium. Please stop. I HATE CHEMISTRY! It is the most boring topic on earth.

Let's take a step back for a moment- OP has written he "had surgery to stop acid from getting in my lungs at night. My Dr. prescribed 2 -40mg Nexium one in the morning and one at evening."

This sounds pretty serious. It probably is a condition which causes great pain, discomfort and anxiety. I suspect this gentleman has been to Walmart to try all the meds you are recommending for him. Add to this that most of us are trying to get better. We are trying to follow our doctor's instructions. According to the FDA, the prescribed treatment is within acceptable standard of care. Would it not be in the doctor's and patient's best interests to have their recommended therapy followed as directed? I believe I would prefer that than to follow a sensationalist's article in New Yorker magazine (although I find their poems and cartoons quite entertaining).

I'm sure that there are cases in which using an "a-bomb" like Nexium instead of a "firecracker" like Prilosec would be kind of a waste of money. Certainly, most cases of indigestion, reflux and "gas" can be resolved with over the counter remedies. If I had OP's condition, I would prefer the "a-bomb".

This gentleman's case seems a bit more serious. I think the doctor has made a very thorough and careful analysis of this problem, and has carefully chosen an agent to correct it. A treatment failure in a serious case like this could be disastrous.

I believe most of us want our physicians to be thorough and very careful when they prescribe remedies. I think we should expect no less from the Humana physician, who has given the client a "cookie cutter" response to the requested medication dosage. Please, if any of you managed care administrative physicians are out there, PLEASE be careful with us.

I think Humana is careless and reckless, and should reconsider its decision based on the severity of the problem, and the medical necessity of the treatment. Just this once. Please?

As for the notion that the doctor is mesmerized by AstraZeneca propaganda, and only wanted to get a Nexium pen, I would say that would be much more preferable than the giant rectal thermometer with spikes on it this gentleman is getting from Humana.

L-Trypotphan and D-Trypophan are not enantiomers.

They would be Diasteromers:

Diastereomers (or diastereoisomers) are stereoisomers that are not enantiomers (non-superimposable mirror images of each other). Diastereomers can have different physical properties and different reactivity. In another definition diastereomers are pairs of isomers that have opposite configurations at one or more of the chiral centers but are not mirror images of each other

To ease your chemical Identification:

If you see an R or an S before the chemical name, like in nexium's case. Nexium is the S-enantiomer of Omeprazole (Prilosec) with the R-enantiomer being optically inert in humans. Upon metabolism by the body, both chemicals break down in to the same chemical that will inhibit proton production.

If you see an L or a D before the chemical name, like in Trypophans's case, you have a Diastereomer.

The difference between them being is are they mirror images of each other. That's what makes enantiomers chemically react the same while diastereomers have very different chemical properties.

Yes, we need more studies. I'm sure managed care will twist the results and shoot down any positive evidence of an expensive new medical breakthrough.

All studies and all medications need to be examined thoroughly. Don't believe every study you read.

I do not want drugs which cause tumors.

L-tryptophan is the "mirror image" of the amino acid D-tryptophan. L-tryptophan is necessary for human life, and is the amino acid responsible for the production of serotonin and melatonin.

D-tryptophan is a deadly neurotoxin used by snails to kill their prey, and is toxic to humans who come in contact with the snail and the purified form of this deadly chemical.

I'm sure these two drugs look the same in a test tube. However, they have totally different biological activities. Go back to Organic chem class.

You are contributing false information to this thread. Organic chem teaches you how to make petroleum products, plastic garbage bags, and explosives. Drug development can only occur through testing on human subjects, and is an issue explored by biochemists and physiologists.

That you do not have a basic grasp of organic chemistry. The molecules are mirror images of each other, but they have the same composition. All they did was remove the portion of Prilosec that did nothing and had no side effects and left the drugs.


Dr. Marcia Angell, former Editor in Chief of the New England Journal of Medicine, spoke at Harvard Medical School to a German magazine on August 16, 2007 and accused AstraZeneca's scientists of deceptively doctoring their comparative studies such that the difference to Omeprazole would look larger, providing a marketing advantage.

http://www.newyorker.com/archive/2004/10/25/041025crat_atlarge


Thomas Scully, head of the Federal Centers for Medicare and Medicaid services also tore into Astra for their aggressive marketing of Nexium. At a conference of the American Medical Association he went so far as to suggest that Astra was using the new drug to overcharge consumers and insurance companies. "You should be embarrassed if you prescribe Nexium," he claimed, "because you're screwing your patients and you're screwing the taxpayers." An AstraZeneca sponsored study showed that esomeprazole 40 mg provided more effective acid control than 40 mg omeprazole.

AstraZeneca claims that esomeprazole provides improved efficacy, in terms of stomach acid control, over racemic omeprazole. Many health professionals have expressed the view that this improvement in efficacy is due to the dose of esomeprazole recommended for therapy rather than any superiority of esomeprazole per se.

An alternative rationale suggested for the use of esomeprazole was the reduction in interindividual variability in efficacy. However the clinical advantage of this hypothesis has not thoroughly been tested in large-scale trials

So you sir, are buying in to AstraZeneca's propaganda over this drug.


And with that. I am done, please continue your insane rantings. I believe the people that wander by will see reason from my posts

Gee, that's funny.

Franzg's own blog (and the FDA) says that higher dosages of Nexium could lead to health problems.

Also, the drug formulary states on 40mg tablet per day.


..... and he wonders why 80mg a day wasn't approved by Humana's medical director.

Hmm.

Well, my boy, I'm tired of trying to argue common sense with you. Don't worry, you won't have to feverishly check ROR anymore for my responses. I know me constantly proving you wrong has worn on you.

Called Humana- They did not answer the phone. So you are wrong again.

Went to Humana's website- very confusing- states certain plans (written by Humana) cover certain drugs, however must refer to "certificate" for limitations. So website is incomplete.

I would suggest that Lexmark decide whether Nexium is covered, since they "wrote" the policy.

I would aqlso suggest that Lexmark dump Humana, and open their own managed care company, since Lexmark is now in the business of writing insurance policies and dictating what medications their employees ingest.

I would suggest that Humana fire Dr. Barczac- he is not needed- Lexmark decides coverage, and medical necessity. Or are you claiming Dr. Barczac is a Lexmark employee?

After this thread, I don't trust your opinion, or the opinion of your goon squad. You believe enantiomers have the same biological activity, and Humana's beloved Dr. Barczac did not deny a 40 cent per day treatment for an ulcer.

I don't want Lexmark or Humana dictating my healthcare- do you? That seems to be the real problem here. We don't want any more tumors, ineffective treatment, and wasteful managed care companies which suggest we go to Walmart to use over the counter meds to treat our serious medical conditions. That's why we have ripoff report. We are getting ripped off!

I suppose Lexmark hired the Dr. denying the prescription.

I suppose Lexmark decides Nexium is "tier 2"

In a previous post, you stated Nexium was "tier 3", and costs $74.53 a month.

In a later post, you state Nexium is "tier 2" and costs $159.69 a month.

You also state these numbers were pasted directly through Humana's website.

Humana does not even cover oral contraceptives. You really are mentally challenged.

During the course of this thread, Humana has raised the price of Nexium, and changed its formulary. Sure, Lexmark can choose which plans it offers, and make small modifications if needed (but I seriously doubt this), but dictate what is denied or covered?

Humana dictates this Nexium prescription.

Humana has a lot to do with Big Pharma, and obviously helps Big Pharma more than its "members".

Now go buy some printer cartridges from Humana, you misguided person. I feel sorry for you.

You are wrong again, Franzg!

Lexmark is a "self insured" policy (AKA an "administrative services only" policy). Which means they wrote the policy and Humana just enforces it.

Call Humana and ask them; 800-448-6262. Or are you too afraid of being proven wrong? Do you research ANYTHING before you say it?

Understand that employers also dictate what drugs will be covered on their plan. Here's an example. I work for a Catholic hospital and they don't want coverage for oral contraceptives on their policy. However, you can still find a "level classification" for them on Humana's website that these drugs typically fall under. So saying that the drug formulary is the same on every single employer's plan is DEAD WRONG.

I Am The Law wins again by a knockout!

Same drug- Bull----

No "gastric carcinoid tumor" is reason enough for me. Prilosec causes it, Nexium does not.

A doctor has to live in this litigious society, and you are suggesting they prescribe drugs which cause tumors.

That is also why Dr. Barczac cannot prescribe medications- only "administrative" license issued to him.

Failure to read FDA labeling of meds could cause lawsuit. Do you oppose the FDA labeling?

Do you suggest all doctors should ignore FDA labeling, and follow treatment recommendation from administrator and blogger?

I don't want tumors. I don't want my doctor to ignore FDA label.

However, if you are OK with this, why don't you recommend that all the asthmatics stop their Xopenex, and start generic albuterol. You think they are the same thing! Do you recommend this?

I recommend you put your left hand in your right glove- Its the same thing.

No go buy a new pair of shoes- Two left ones, of course, they are the same anyway.

That is just about the most feeble argument I have seen yet. Please go away.

Same drug- Bull----

No "gastric carcinoid tumor" is reason enough for me. Prilosec causes it, Nexium does not.

A doctor has to live in this litigious society, and you are suggesting they prescribe drugs which cause tumors.

That is also why Dr. Barczac cannot prescribe medications- only "administrative" license issued to him.

Failure to read FDA labeling of meds could cause lawsuit. Do you oppose the FDA labeling?

Do you suggest all doctors should ignore FDA labeling, and follow treatment recommendation from administrator and blogger?

I don't want tumors. I don't want my doctor to ignore FDA label.

However, if you are OK with this, why don't you recommend that all the asthmatics stop their Xopenex, and start generic albuterol. You think they are the same thing! Do you recommend this?

I recommend you put your left hand in your right glove- Its the same thing.

No go buy a new pair of shoes- Two left ones, of course, they are the same anyway.

That is just about the most feeble argument I have seen yet. Please go away.

Prilosec is the racemate, it can have the inactive enantiomer removed and you get nexium.

Nexium was the REPLACEMENT for prilosec because AstraZeneca was losing their patent for Omeprazole. They knew it would go generic and over the counter, so nexium was their answer. As soon as its patent expires, they will have something else I'm sure.

If you would like I can pull you the relevant peer reviewed literature on omeprazole. You will see that it is the SAME DRUG as nexium.

I have Achalasia so I have tried them all. They are all proton pump inhibiters.

Now. I don't really care what you think at this point except, as a chemist, I have to correct one thing:

"enantiomer of Prilosec (a purified form with greater efficacy and safety)"

Enantiomers are not purified forms of the same chemical. They are different stereoisomers of the same chemical. Its like comparing your right hand to your left hand. They are both hands, one just has the thumb pointing a different direction.

Enantiomers have, when present in a symmetric environment, identical chemical and physical properties except for their ability to rotate plane-polarized light. Enantiomers of each other often do have different chemical properties related to other substances that are also enantiomers.

So your claim that they are enantiomers proves to me that neither priolosec nor nexium is any better or worse than the other. Since they are chemically the same, and do the same thing. A lab somewhere simply altered the configuration of the molecule allowing them to get a patent on it, that way they could market it as a new drug that does THE SAME THING.

Nexium does not cause "gastric carcinoid tumors". Prilosec does.

Stop being stupid.

Higher doses are approved by FDA. Not approved by Humana.

Nexium is tier 2 on Humana's formulary, not "Lexmark's" Restrictions on Nexium placed by Humana's "physicians", not Lexmark's. Nexium denied by Humana, not Lexmark.

Humana wrote policy and formulary, was approved and purchased by Lexmark to offer to employees. Lexmark did not "write" the policy or the formulary. If they did, they would not need Humana.

Prilosec and TUMS ore available at Walmart. I suggest Dr. Barczac take these if he gets a bleeding ulcer requiring surgery.

Franzg,

These are your own words from a previous blog:

"Prilosec has a warning in the package insert ('mutagenesis' section) warning that higher dosages may cause 'gastric carcinoid tumors'."

"The same warning has also crept into the package insert for Nexium, however the insert states that only Prilosec has been shown to have this effect. Since Nexium is an enantiomer of Prilosec (a purified form with greater efficacy and safety), the FDA decided not to take any chances and include Prilosec's evidence in the Nexium packaging."

So, in summation, what you're saying is that there is a possibility of higher doses of Nexium harming the user. Hmmm. So, when the medical director denied the higher dosage request, you flew off the handle and challenged his knowledge and reputation. From what I'm reading here, your own blog is supporting his decision.

Here's the information on Nexium pasted directly from Humana's website.

Coverage Information

Plan: National Plan
Plan Year: 2008 2009
Coverage: Covered Covered
Tier: Preferred Brand (Tier 2) Preferred Brand (Tier 2)
Quantity Limits: 30 for 30 Days 30 for 30 Days



Coverage Information

Plan: Medicare Standard PDP Plans
Plan Year: 2009
Coverage: Covered
Tier: Preferred Brand (Tier 2)
Quantity Limits: 30 for 30 Days



Coverage Information

Clinical Information: View Clinical Information (side effects, drug interactions, etc.) in the Drug Dictionary.
Estimated Price: $159.69
This estimated price is provided for illustrative purposes only. To view your cost please, log in
Your Cost: Current members can price the drug at your local pharmacy by logging into MyHumana

To a lesser extent, the decision was also based on what dosage the employer (Lexmark) wanted to cover. So between the possible harm to the patient by taking the higher dose and enforcing the policy according to the employer's design, the medical director had no choice but to deny a higher dosage request.

Now get back to pretending to be Opana.

Franzg,

These are your own words from a previous blog:

"Prilosec has a warning in the package insert ('mutagenesis' section) warning that higher dosages may cause 'gastric carcinoid tumors'."

"The same warning has also crept into the package insert for Nexium, however the insert states that only Prilosec has been shown to have this effect. Since Nexium is an enantiomer of Prilosec (a purified form with greater efficacy and safety), the FDA decided not to take any chances and include Prilosec's evidence in the Nexium packaging."

So, in summation, what you're saying is that there is a possibility of higher doses of Nexium harming the user. Hmmm. So, when the medical director denied the higher dosage request, you flew off the handle and challenged his knowledge and reputation. From what I'm reading here, your own blog is supporting his decision.

Here's the information on Nexium pasted directly from Humana's website.

Coverage Information

Plan: National Plan
Plan Year: 2008 2009
Coverage: Covered Covered
Tier: Preferred Brand (Tier 2) Preferred Brand (Tier 2)
Quantity Limits: 30 for 30 Days 30 for 30 Days



Coverage Information

Plan: Medicare Standard PDP Plans
Plan Year: 2009
Coverage: Covered
Tier: Preferred Brand (Tier 2)
Quantity Limits: 30 for 30 Days



Coverage Information

Clinical Information: View Clinical Information (side effects, drug interactions, etc.) in the Drug Dictionary.
Estimated Price: $159.69
This estimated price is provided for illustrative purposes only. To view your cost please, log in
Your Cost: Current members can price the drug at your local pharmacy by logging into MyHumana

To a lesser extent, the decision was also based on what dosage the employer (Lexmark) wanted to cover. So between the possible harm to the patient by taking the higher dose and enforcing the policy according to the employer's design, the medical director had no choice but to deny a higher dosage request.

Now get back to pretending to be Opana.

Franzg,

These are your own words from a previous blog:

"Prilosec has a warning in the package insert ('mutagenesis' section) warning that higher dosages may cause 'gastric carcinoid tumors'."

"The same warning has also crept into the package insert for Nexium, however the insert states that only Prilosec has been shown to have this effect. Since Nexium is an enantiomer of Prilosec (a purified form with greater efficacy and safety), the FDA decided not to take any chances and include Prilosec's evidence in the Nexium packaging."

So, in summation, what you're saying is that there is a possibility of higher doses of Nexium harming the user. Hmmm. So, when the medical director denied the higher dosage request, you flew off the handle and challenged his knowledge and reputation. From what I'm reading here, your own blog is supporting his decision.

Here's the information on Nexium pasted directly from Humana's website.

Coverage Information

Plan: National Plan
Plan Year: 2008 2009
Coverage: Covered Covered
Tier: Preferred Brand (Tier 2) Preferred Brand (Tier 2)
Quantity Limits: 30 for 30 Days 30 for 30 Days



Coverage Information

Plan: Medicare Standard PDP Plans
Plan Year: 2009
Coverage: Covered
Tier: Preferred Brand (Tier 2)
Quantity Limits: 30 for 30 Days



Coverage Information

Clinical Information: View Clinical Information (side effects, drug interactions, etc.) in the Drug Dictionary.
Estimated Price: $159.69
This estimated price is provided for illustrative purposes only. To view your cost please, log in
Your Cost: Current members can price the drug at your local pharmacy by logging into MyHumana

To a lesser extent, the decision was also based on what dosage the employer (Lexmark) wanted to cover. So between the possible harm to the patient by taking the higher dose and enforcing the policy according to the employer's design, the medical director had no choice but to deny a higher dosage request.

Now get back to pretending to be Opana.

Franzg,

These are your own words from a previous blog:

"Prilosec has a warning in the package insert ('mutagenesis' section) warning that higher dosages may cause 'gastric carcinoid tumors'."

"The same warning has also crept into the package insert for Nexium, however the insert states that only Prilosec has been shown to have this effect. Since Nexium is an enantiomer of Prilosec (a purified form with greater efficacy and safety), the FDA decided not to take any chances and include Prilosec's evidence in the Nexium packaging."

So, in summation, what you're saying is that there is a possibility of higher doses of Nexium harming the user. Hmmm. So, when the medical director denied the higher dosage request, you flew off the handle and challenged his knowledge and reputation. From what I'm reading here, your own blog is supporting his decision.

Here's the information on Nexium pasted directly from Humana's website.

Coverage Information

Plan: National Plan
Plan Year: 2008 2009
Coverage: Covered Covered
Tier: Preferred Brand (Tier 2) Preferred Brand (Tier 2)
Quantity Limits: 30 for 30 Days 30 for 30 Days



Coverage Information

Plan: Medicare Standard PDP Plans
Plan Year: 2009
Coverage: Covered
Tier: Preferred Brand (Tier 2)
Quantity Limits: 30 for 30 Days



Coverage Information

Clinical Information: View Clinical Information (side effects, drug interactions, etc.) in the Drug Dictionary.
Estimated Price: $159.69
This estimated price is provided for illustrative purposes only. To view your cost please, log in
Your Cost: Current members can price the drug at your local pharmacy by logging into MyHumana

To a lesser extent, the decision was also based on what dosage the employer (Lexmark) wanted to cover. So between the possible harm to the patient by taking the higher dose and enforcing the policy according to the employer's design, the medical director had no choice but to deny a higher dosage request.

Now get back to pretending to be Opana.

Prilosec has a warning in the package insert ("mutagenesis" section) warning that higher dosages may cause "gastric carcinoid tumors".

The same warning has also crept into the package insert for Nexium, however the insert states that only Prilosec has been shown to have this effect. Since Nexium is an enantiomer of Prilosec (a purified form with greater efficacy and safety), the FDA decided not to take any chances and include Prilosec's evidence in the Nexium packaging.

An experienced gastroenterologist may favor using Nexium over Prilosec in certain severe cases (such as the one in the original post) to avoid such negative outcomes, since there have been no controlled trials indicating Nexium causes "gastric carcinoid tumors".

The pharmaceutical industry has taken a lot of criticism for purifying their products to increase safety and efficacy. Astra Zeneca has been criticized for trying to "extend the patent" on Prilosec in this manner.

If one actually looks at the benefits scientifically, the merits of this practice can be appreciated. Xopenex, for example, is much more efficacious than racemic albuterol. The most obvious example is Thalidomide, which causes tumors and birth defects. However, the active enantiomer has no such effects, and has superior efficacy.

Physicians go to medical school and a must endure a relentless "board certification" process, and are required to stay educated on such issues. That is why I object to managed care's practice of dubbing Prilosec "the same drug" as Nexium. The FDA does not think they are the same thing, and neither do I. I would rather pay an experienced gastroenterologist to treat my ulcer than a "medical director" for managed care who carries only an administrative license (meaning the doctor cannot legally prescribe medications). I think it is a waste of our heathcare dollar to spend it on administrative salaries for reckless physicians who can't pass their board exams, and can't get a job anywhere else.

Hope this helps. Our healthcare is important, and should not be left in the hands of lawyers and lobbyists.

Please show me this FDA warning. I work in an Oncology hospital and have never seen this. We do prescrbe Nexuim 40 mg bid (twice a day) with a prior authorization and get it approved by many of our insurers. Our patients have Barrett's esophagus, serious documented ulceration and gastritis by endoscopy. This is part of what I do for a living, getting medictions approved by insurance payers and fighting with them when they don't.

Nobody seems to be aware that the OP has had surgery and a long history of stomach problems.

The reason why Humana denies the 1 Nexium a day has nothing to do with kickbacks, drug addicts, the FDA, "Lexmark", or Swedish (or UK) drug companies.

Nor is it the reason why you recommend Prilosec for this client.

Please read thread and original complaint. Prilosec is available at Walgreen's and CVS without a prescription. That is why Humana refuses the FDA approved treatment with Nexium.

Humana does not have to pay 1 penny for over the counter remedies, such as Rolaids, TUMS, Pepto-Bismol, and Prilosec. It is kind of an insult to the OP to suggest that they never even tried these OTC products.

It is also an insult to the OP's doctor, who probably realizes the client needs more than 40 mg per day of Nexium. The doctor may have also been educated to the fact that there is an FDA warning about using higher doses of Prilosec, and that the higher doses may cause "gastric carcinoid tumors". Nexium has no such warning. Maybe the OP's physician was trying to deliver safe effective care to the client.

Humana's administrative physicians do not have licenses to treat patients. That's why they work for Humana.

I don't want any "gastric tumors" and would not trust ANY Humana decision after reading this thread. Humana has wasted time, money, and has possibly delayed the proper care of this client.

If Humana is so intent on treating its own clients with over the counter ointments and powders, maybe they should open a Humana quack shack at Wal Mart.

Oh, sorry, Humana has already done that. Perhaps a kiosk at Starbucks will be Humana's next scheme.

I have used Nexium and Aciphex and Prilosec. The only difference for my esophogeal issues is that I have to take twice as much prilosec. I was on nexium until my insurance pulled it from their allowed medicines. My doctor simply switched me to prilosec and doubled my dosage. It does the SAME THING.

I really could care less what humana is and isn't doing to you. I was trying to point out that there IS an alternative that is SCIENTIFICALLY proven to work just as well. If you would like I can pull out some peer reviewed medical journals illustrating that point.

I also hate to say it but AstraZenica's corporate offices are in London, not sweden, with R+D and manufacturing divisions in Sweden, UK, and the US.

So YES your nexium IS manufactured in the US and thus IS under FDA guidelines. Next time you go to a pharmacist, why don't you ask how much nexium costs the pharmacy and you will see what the cost is. On my last refill (been over a year) it was $168.86 before insurance was applied.

Yes I could have gone online and ordered pills from a clearinghouse that got them from India, Canada, or Mexico, and yes they would have been cheaper, BUT I don't trust the guildlines those countries use in the manufacturing process of their drugs.

The only reason you are getting denied for Nexium is that there are cheaper alternatives available that are just as effective. Nothing is stopping you from buying the nexium on your own. This particular insurance company has made the decision what medicines they will cover. Which is THEIR RIGHT. If you don't like the policies of your insurance company, then perhaps you should get a new insurance company.

Franzg, you are truly a broken record.

The Nexium isn't being denied. Just the higher dosage. I have posted the information from the Humana website concerning the Lexmark drug formulary TWICE! 40mg approved, 80 mg isn't. This obviously isn't hidden information.

The Medical director isn't denying the higher dose to save money. He is denying the higher dose because he is enforcing the rules of the policy set forth BY THE EMPLOYER (Lexmark)! If you want to spit on someone's reputation, try spitting at the right party.

Pack it up, man. You've lost this argument. Your LIES about a "bailout" for Humana and your socialistic political rantings mean nothing against CONTRACT LAW and the employer's policies. Everyone loses an argument at some point. Get over it.

That's right, victims of Humana!

Dare to complain (like the OP)- All you get is Silicon Sally-

Post on this forum, and a bunch of Humana puppets come out of the woodwork to flame and criticize you- You must be a "drug addict" if you get Nexium. Nexium costs more than $200 a month. Prilosec works "just as well" (against a placebo). Nexium is bad because doctors get a "kickback" when they write for it. You must file a "whistleblower" lawsuit if you can get it cheaper by carefully shopping. Now we are being told Prilosec and Nexium are manufactured by a US drug company.

Last I checked, Astra zeneca was in Sweden.

What will they come up with next? Maybe the next post will be another Humana liar telling us ulcers don't exist, and is just a psychiatric condition.

What's with these people, anyway- are they "anti-Nexium" or something?

I still don't understand the hostility-Why should we be paying a moronic doctor to deny a prescription, then do a "peer review"? Humana is just a waste of time and money- the OP could be cured by now! It doesn't really cost that much to just give the OP some Nexium- Have you all gone mad???????

And don't forget You have no right to complain! You should consider yourself LUCKY to have Nexium covered AT ALL! OMG!! Aren't we so LUCKY! The OP ain't so lucky- Please read OP.

Now go and pop some placebos for your "erosive esophagitis".

Yes, you can buy it as an uninsured websurfer. You are buying it from another country, where it is manufactured cheaply and they do not have the same protocol as american drug companies.

Couple that with the fact that in most states its illegal to order drugs like that through the mail without your doctor involved.

You should consider yourself lucky AT ALL that nexium is covered under your insurance. Most companies will not cover it because of the cost, especially since there are much cheap alternatives on the market.

Prilosec HAS been proven effective in healing esophageal lesions. Its one of the reasons I take it.

Erosive Esophagitis

In a U.S. multicenter double-blind placebo controlled study of 20 mg or 40 mg of PRILOSEC Delayed-Release Capsules in patients with symptoms of GERD and endoscopically diagnosed erosive esophagitis of grade 2 or above, the percentage healing rates (per protocol) were as follows:

Week 20 mg PRILOSEC
(n = 83) 40 mg PRILOSEC
(n = 87) Placebo
(n = 43)
4 39** 45** 7
8 74** 75** 14
** (p
In this study, the 40 mg dose was not superior to the 20 mg dose of PRILOSEC in the percentage healing rate. Other controlled clinical trials have also shown that PRILOSEC is effective in severe GERD. In comparisons with histamine H2-receptor antagonists in patients with erosive esophagitis, grade 2 or above, PRILOSEC in a dose of 20 mg was significantly more effective than the active controls. Complete daytime and nighttime heartburn relief occurred significantly faster (p
In this and five other controlled GERD studies, significantly more patients taking 20 mg omeprazole (84%) reported complete relief of GERD symptoms than patients receiving placebo (12%).
Long Term Maintenance Of Healing of Erosive Esophagitis

In a U.S. double-blind, randomized, multicenter, placebo controlled study, two dose regimens of PRILOSEC were studied in patients with endoscopically confirmed healed esophagitis. Results to determine maintenance of healing of erosive esophagitis are shown below.

PRILOSEC
20 mg once daily
(n = 138) Life Table Analysis
PRILOSEC
20 mg 3 days per week
(n = 137) Placebo
(n = 131)
Percent in endoscopic remission at 6 months *70 34 11
*(p
In an international multicenter double-blind study, PRILOSEC 20 mg daily and 10 mg daily were compared with ranitidine 150 mg twice daily in patients with endoscopically confirmed healed esophagitis. The table below provides the results of this study for maintenance of healing of erosive esophagitis.


In patients who initially had grades 3 or 4 erosive esophagitis, for maintenance after healing 20 mg daily of PRILOSEC was effective, while 10 mg did not demonstrate effectiveness.

As you can see from this study (and I can get you a copy if you wish) Omeprazole is indeed useful in healing so long as the dosage is greater than 20mg.

As for cost, you are way off on your cost.

AstraZenica, the maker of nexium, offer a program to get 50$ off per month on nexium. If it was as cheap as you say, wouldn't it be free then?

Pharmacies pay between 150-200$ per month for this medicine. Your INSURANCE pays the difference between your 20 or 30 bucks a month and this price.

Franzg, what you're suggesting about an insurance carrier posting false figures for drugs and services constitutes extreme fraud. If you feel like Humana is doing this, then by all means, be a whistleblower. File a lawsuit. You'd better be sure you're right, because you're opening yourself up for a countersuit if you're just making it up.

Post the court information here and I'll be more than happy to join your crusade since I'm a Humana member myself.

(((ROR redacted)))
40 mg 168 tabs=$129.50

40 mg tabs X 30= $23.13

Sorry. Humana pays thousands to save $25.

Humana would like you to believe your doctor is "wasting money" by giving you a fake price for Nexium. Fact is, Humana charges the client more than it pays for it. It is a scam!

Nexium is scientifically proven to heal esophageal lesions. Prilosec does not.

I believe Humana is totally scamming the American consumer. By the sound of these responses to customer complaints, I am also convinced Humana does not have any interest in the OP's health or well being.

Am I to believe that Humana is so inept that it must pay over $300 for a prescription that would cost an uninsured websurfer $23.13? I think not. Humana inflates the prices of medications to keep you from getting care at a decent price.

Humana has a lot more to do with Big Pharma than you think.

CLICK here to see why Rip-off Report, as a matter of policy, deleted either a phone number, link or e-mail address from this Report.

Nexium is NOT 12$ for 30 days at all. That might be what YOU pay AFTER insurance. Last time I got nexium filled it was close to 200$ for a 30 day supply. I had to pay 30$ after insurance.

You can use prilosec. I have tried nexium, aciphex, and prilosec. They all do the same thing and prilosec is much cheaper.

Do not listen to these Humana fanboys/fangirls! Previous posts states 'The FDA and manufacture guidelines for Nexium 40mg are 30 pills for 30 days.'

This is BS.

For certain conditions, FDA allows max of 80 mg. FDA also allows 'maintenence' treatment w/ Nexium for certain conditions. (I am assuming 'maintenance' is more than 30 days). It is only Humana that claims 'The FDA and manufacture guidelines for Nexium 40mg are 30 pills for 30 days.' We are being lied to again.

I grow quite weary of the litany of lame excuses by Humana cronies. I'm sick of surfing the web to find I have been misled. Please find something more constructive to do than to waste our time lying to us.

Read this thread. I was first told that Humana denied it because it is 'not medically necessary'. However, after further research, I discovered that there are certain conditions that warrant Nexium with no available generic substitutions. I was then told Nexium was denied because the prescribing doctor received a 'kickback' for Nexium. After being sent on a wild goose chase, I discovered no instances where a doctor received a 'kickback' for writing a Nexium prescription. I was then told Nexium was denied because if it was covered, drug addicts would 'get high' on Nexium. I was then told it was denied because it is 'in print' on the web, and told everyone needs to get over it.

Sorry, buddy/buddette, I'M NOT OVER IT! 30 Nexium is $12. I don't know how much Humana pays the doctor to surf the web and stamp 'denied' on a claim, or how much Humana pays the doctor to do a 'peer review', but I'm willing to bet it is more than $12.

Maybe Humana believes the OP did not get ripped off. After reading this thread, I am sure WE ARE ALL GETTING FLEECED BY HUMANA. Please people, fight back against these nincompoops. Humana is spending thousands of dollars of our money to deny FDA approved treatment to save $12. This kind of waste and fiscal irresponsibility is why we are in a recession, and also have a healthcare crisis.

She's still WRONG.

Franzg,

Your response to Amanda's post was titled, "Another feeble rebuttal by Humana fanboys". I believe that Amanda is a woman's name.

Do not listen to these Humana fanboys! Previous posts states "The FDA and manufacture guidelines for Nexium 40mg are 30 pills for 30 days."

This is BS.

For certain conditions, FDA allows max of 80 mg. FDA also allows "maintenence" treatment w/ Nexium for certain conditions. (I am assuming "maintenance" is more than 30 days). It is only Humana that claims "The FDA and manufacture guidelines for Nexium 40mg are 30 pills for 30 days." We are being lied to again.

I grow quite weary of the litany of lame excuses by Humana cronies. I'm sick of surfing the web to find I have been misled. Please find something more constructive to do than to waste our time lying to us.

Read this thread. I was first told that Humana denied it because it is "not medically necessary". However, after further research, I discovered that there are certain conditions that warrant Nexium with no available generic substitutions. I was then told Nexium was denied because the prescribing doctor received a "kickback" for Nexium. After being sent on a wild goose chase, I discovered no instances where a doctor received a "kickback" for writing a Nexium prescription. I was then told Nexium was denied because if it was covered, drug addicts would "get high" on Nexium. I was then told it was denied because it is "in print" on the web, and told everyone needs to get over it.

Sorry, buddy, I'M NOT OVER IT! 30 Nexium is $12. I don't know how much Humana pays the doctor to surf the web and stamp "denied" on a claim, or how much Humana pays the doctor to do a "peer review", but I'm willing to bet it is more than $12.

Maybe Humana believes the OP did not get ripped off. After reading this thread, I am sure WE ARE ALL GETTING FLEECED BY HUMANA. Please people, fight back against these nincompoops. Humana is spending thousands of dollars of our money to deny FDA approved treatment to save $12. This kind of waste and fiscal irresponsibility is why we are in a recession, and also have a healthcare crisis.

Before you complain, check the facts. The FDA and manufacture guidelines for Nexium 40mg are 30 pills for 30 days. There is a reason for this!! Yes, your doctor can prescribe anything they feel is necessary, however your insurance company doesn't have to cover it. Your prescription gives the pharmacy the right to fill the pills. You can fill 30 for 30 through your insurance and then pay out of pocket. The authorization process looks for medical necessity, your doctor didn't file the correct information if it was denied. Your doctor can do a peer to peer if they disagree with the denail. And for future, the direct number for pharmacy customer service at humana is 1-800-558-4444

You can check out www.fda.gov for guidelines on prescription drugs

We have NO RIGHT to complain that Humana refuses to cover the standard of care for an ulcer?

Heck, Humana even pays a doctor to sit in a mahogany paneled office in a crystal palace to surf the web and state what is in print.

Another victory and gag order from a Humana crony!

Seems like a lot of hot air from Humana for a pill that costs 40 cents. Humana needs to get it together for once. I think Humana may have a little more to do with Big Pharma than we think.

It must be due to the kickbacks Humana negotiators get from the pharmaceutical companies for contracts.

Now I'm positive we are being ripped off by Humana. This is the most ridiculous waste of tax dollars yet.

Fire the Humana doctor- we only need a web surfer to show us whats in print.

The Humana money party needs to stop. It is out of control.

Franzg, I don't know why you argue. I really, really don't. Again, this dosage limitation is in print. I showed you the information from the Humana.com website. I'll paste it here again.


Step Three : Search Results


NEXIUM

10 MG PACKET 20 MG CAPSULE 20 MG PACKET 40 MG CAPSULE 40 MG PACKET Looking for an Individual Plan?
HumanaOne offers affordable health insurance for individuals and families


Coverage Information
Plan: Rx3 (Change Plan)
Coverage: Covered
Tier: Level 3
Quantity Limits: 30 for 30 Days

Drug Information
Clinical Information: View Clinical Information (side effects, drug interactions, etc.) in the Drug Dictionary.
Estimated Price: $74.53
This estimated price is provided for illustrative purposes only. To view your cost please, log in
Your Cost: Current members can price the drug at your local pharmacy by logging into MyHumana
Generic Equivalent: None Available

You lost, boy. This is copied directly from their website. Note the quantity limits. The medical director isn't denying the second daily tablet to cut costs. (Stating otherwise makes you guilty of libel.) He is merely upholding the policy as it is written. This is another obvious situation where someone didn't read their policy. It's in black and white, people. Humana isn't the bad guy here. I guess it's easier for Bill to blame someone else instead of take responsibility for his own negligence.

Again, I thank you for your advice.

You have been so helpful to this victim.

"Google" states it is not legal for doctors to receive "kickbacks" from drug companies. I'm sorry you think that this is a legal practice. I'm also sorry that you think this victim had to have 1 pill a day denied because his doctor received a "kickback".

I think your posts are irrelevant. If you are trying to prove that this client's doctor got a kickback, you will have to do a little better than telling us all to "google" it.

This client's Nexium was not denied because of a "kickback". He is a victim of manage care's stinginess and ineptitude.

If you really believe you are helping this client, please be more specific about how "kickbacks" have resulted in this client's denial of medically needed drug therapy.

I simply don't believe that it is true. I believe the prescription was denied and appealed, then denied again by Dr. Barczac in an effort to cut costs to Humana.

Please tell us about the "kickbacks". We are all eagerly waiting your reply. We think it is a crime that should be reported.

Again, I thank you for your advice.

You have been so helpful to this victim.

"Google" states it is not legal for doctors to receive "kickbacks" from drug companies. I'm sorry you think that this is a legal practice. I'm also sorry that you think this victim had to have 1 pill a day denied because his doctor received a "kickback".

I think your posts are irrelevant. If you are trying to prove that this client's doctor got a kickback, you will have to do a little better than telling us all to "google" it.

This client's Nexium was not denied because of a "kickback". He is a victim of manage care's stinginess and ineptitude.

If you really believe you are helping this client, please be more specific about how "kickbacks" have resulted in this client's denial of medically needed drug therapy.

I simply don't believe that it is true. I believe the prescription was denied and appealed, then denied again by Dr. Barczac in an effort to cut costs to Humana.

Please tell us about the "kickbacks". We are all eagerly waiting your reply. We think it is a crime that should be reported.

Franzg, argue all you want. Doctors receive kickbacks from drug companies; sad but true. As for naming names, frankly, I'm not my job just because you won't Google something. I understand your limited intelligence may be an obstacle to finding the information that you want online, so my advice is to ask an adult to help you.

Now I know you are useless and ill mannered as well.

You are no help to anyone on this site.

Now be a man and tell us at least one (pretty please?) doctor receiving a "kickback" from big pharma. Stop being a sissy-boy.

Now go back to work, and release all the hospitalized schizophrenics out into the community. I'm sure mental health is "carved out" of our Humana plans.

Um, ok, Franzg, you want me to list every single doctor in America that has received kickbacks from drug vendors and fit all that info into one blog. I'll get right on that. (Sarcasm) Google it yourself, you potted plant.

The public deserves to know. We need to boycott the physicians receiving a kickback...

Please name names, since you do this "all the time".

You could actually be helpful for a change.

Stacey, did you ever think that the agreement stating that doctor's don't receive kickbacks from drug companies is exclusive to your particular employer? Sweetie, I work for a major Chicago hospital in the Billing and Coding department (in fact, I run that department). I also work closely with payroll, Cash Box, and Accounts Paid and Received. I see this kickback information at least ten times a day. I think I'd know what I was talking about.

I take Nexium - Never had a problem getting it through my Insurance
As for doctors taking kickbacks - try again
I work for a Health Care Company and all physicians who are contracted through the company must sign agreements which include a clause that states they will not receive kickbacks from any pharmaceutical company - violation is terms for termination, legal matters and such
Pharmaceutical reps leave all kinds of crap - pens, post its, samples - that does not mean the physician is getting a kickback from the drug company
Get real - and yes the pharmacy will not refill my script until the day it expires

I take Nexium - Never had a problem getting it through my Insurance
As for doctors taking kickbacks - try again
I work for a Health Care Company and all physicians who are contracted through the company must sign agreements which include a clause that states they will not receive kickbacks from any pharmaceutical company - violation is terms for termination, legal matters and such
Pharmaceutical reps leave all kinds of crap - pens, post its, samples - that does not mean the physician is getting a kickback from the drug company
Get real - and yes the pharmacy will not refill my script until the day it expires

I take Nexium - Never had a problem getting it through my Insurance
As for doctors taking kickbacks - try again
I work for a Health Care Company and all physicians who are contracted through the company must sign agreements which include a clause that states they will not receive kickbacks from any pharmaceutical company - violation is terms for termination, legal matters and such
Pharmaceutical reps leave all kinds of crap - pens, post its, samples - that does not mean the physician is getting a kickback from the drug company
Get real - and yes the pharmacy will not refill my script until the day it expires

I take Nexium - Never had a problem getting it through my Insurance
As for doctors taking kickbacks - try again
I work for a Health Care Company and all physicians who are contracted through the company must sign agreements which include a clause that states they will not receive kickbacks from any pharmaceutical company - violation is terms for termination, legal matters and such
Pharmaceutical reps leave all kinds of crap - pens, post its, samples - that does not mean the physician is getting a kickback from the drug company
Get real - and yes the pharmacy will not refill my script until the day it expires

Yeah, I guess all the drug addicts just LOVE Nexium.

This guy's got an ulcer, you idiot!

I'm sure if the doctor ordered some cheap morphine, Humana would gladly pay.

I don't know how much Dr. Barczac makes, but I'm sure its a lot more than the guy with an ulcer.

If what you say is true, Dr. Barczac has no business even knowing what this guy takes. Why does he need to be paid for sticking his nose in this person's healthcare? You claim it is up to the employer, and what is posted on the web.

Why not pay my employer to do the EOBs? According to you, they are responsible for this ridiculous mess in the first place.

I would never in my lifetime work for managed care. Managed care has no interest in advancing science, technology, or even simplifying the delivery of basic care. The bailout money is really the icing on the cake.

Now go back and micromanage someone's care. I think there may be a patient out there using more than the maximum allowable number of Q-tips under their Humana policy.

Franzg said that this patient's Nexium was "denied by an administrative physician behind a desk making a bundle of cash." I don't know about the "bundle of cash part", but yes, this case was reviewed by a medical director. Franzg fails to realize that a second 40mg pill was not covered by the formulary. (The patient's employer writes the formulary.) I have pasted that forumulary information from Humana's website a few posts above this one. He goes on to say, "It is an FDA approved treatment". Well, no one's arguing that. He seems to think that Humana should approve any and all Rx claims. Using that logic, people addicted to pain pills could score titanic amounts of controlled substances to feed their habit. I don't think he understands that even Nexium is a controlled substance and that there are standard dosages of medications. He also doesn't understand that insurance carriers will do medical review, but that doesn't guarantee approval.

I'm fairly positive that this person works for a rival insurance company because he only seems to spout his hatred for managed care at Humana directly.

It was denied by an administrative physician behind a desk making a bundle of cash.

It is an FDA approved treatment.

Yes, we all know Humana refuses to cover the approved treatment. "Its all over a website". Big deal.

Eliminate the administrative physician. It's a waste of money.

Most importantly, Humana SHOULD cover FDA approved treatments. What it is doing is not in the best interest of public health.

Franzg, the Nexium wasn't denied, just a dosage of 80mg instead of the clearly approved 40mg. (I pasted this info straight from the Humana website a few posts above this one.) I figure since you work for a managed care company, you would've seen this situation before.

You must be nuts.

I'm a victim, just like everyone else you harass and rip on this site.

I'll work on another managed care company when their lunacy trumps that of Humana.

It seems if the managed care companies could spend less money denying 1 extra pill a day, in the long run we would be healthier, and at a lesser cost. The 6 figures this "administrative doctor" makes a year is designed to add legitimacy to the ludicrous denying of claims filed by Humana victims.

It just seems wasteful to spend all the healthcare money on these administrative actions. We could be curing people of their illnesses.

Franzg said that Humana stock is "circling the drain"???? Ok, I don't know what stock reports you're looking at, but HUM has been rising consistently for over two weeks. (I have a policy and some stock with Humana.)

Franzg, I'm accusing you of working for a rival insurance company. Considering your cornicopia of lies, half-baked accusations, and anger-filled rants about Humana, that can be the only possible solution. I haven't seen you spouting your venom about other carriers on ROR, so I'm pretty confident that I'm correct. So, which company do you work for? Anthem? United? Aetna? Come clean, man.

So why pay this doctor anything to deny the claim...

Humana need not pay an "administrative physician" to deny the prescription. Just look it up on the web!

No wonder Humana stock is circling the drain. They are wasting our $640 billion a year of tax dollars paying "qualified physicians" to surf the web, so they can inform clients their FDA approved, doctor recommended treatment (with no generic equivalent) is NOT EVEN COVERED!

What a waste of tax dollars. I say end this little managed care money party once and for all.

Just to put this issue to bed, I took the liberty of going to Humana's website and looking for the limitations on Nexium.

Step Three : Search Results


NEXIUM

10 MG PACKET 20 MG CAPSULE 20 MG PACKET 40 MG CAPSULE 40 MG PACKET Looking for an Individual Plan?
HumanaOne offers affordable health insurance for individuals and families


Coverage Information
Plan: Rx3 (Change Plan)
Coverage: Covered
Tier: Level 3
Quantity Limits: 30 for 30 Days

Drug Information
Clinical Information: View Clinical Information (side effects, drug interactions, etc.) in the Drug Dictionary.
Estimated Price: $74.53
This estimated price is provided for illustrative purposes only. To view your cost please, log in
Your Cost: Current members can price the drug at your local pharmacy by logging into MyHumana
Generic Equivalent: None Available

This is copied directly from their website. Please note the quantity limits. So, I guess what I'm saying here is that this information is clearly posted for the member to see. I'm sorry you don't have coverage for the second daily tablet, but the medical director isn't denying the second daily tablet "just because". The policy rules apply to everyone, not just you.

I don't need your help.

Humana needs help.

That is why it is necessary for the US government to infuse money from the taxpayer funded stimulus package (the thing regular citizens call 'bailout' money) to cover premiums of Humana's recently unemployed clients.

I think you should actually try to sue. You seem to object to this kind of statement.

As for the denial of this client's Nexium, I believe Dr. Barczac is wrong.

Nexium is the only drug marketed in the US that is actually approved by the FDA to heal esophageal lesions. Cheap alternatives have not been approved by the FDA. Substituting for Nexium is a gamble on this person's health, and Humana is willing to take that risk. (Remember, Humana assumes no liability for the outcome of the cheap medical treatment). It is always up to the patient and doctor to somehow "scramble" to get the proper treatment initiated.

The $640 billion dollars spent each year on healthcare in this country could go to better use than to fund Dr. Barczac's denials of usual, customary, FDA approved, and effective medical care.

I don't need your help.

Humana needs help.

That is why it is necessary for the US government to infuse money from the taxpayer funded stimulus package (the thing regular citizens call 'bailout' money) to cover premiums of Humana's recently unemployed clients.

I think you should actually try to sue. You seem to object to this kind of statement.

As for the denial of this client's Nexium, I believe Dr. Barczac is wrong.

Nexium is the only drug marketed in the US that is actually approved by the FDA to heal esophageal lesions. Cheap alternatives have not been approved by the FDA. Substituting for Nexium is a gamble on this person's health, and Humana is willing to take that risk. (Remember, Humana assumes no liability for the outcome of the cheap medical treatment). It is always up to the patient and doctor to somehow "scramble" to get the proper treatment initiated.

The $640 billion dollars spent each year on healthcare in this country could go to better use than to fund Dr. Barczac's denials of usual, customary, FDA approved, and effective medical care.

I don't need your help.

Humana needs help.

That is why it is necessary for the US government to infuse money from the taxpayer funded stimulus package (the thing regular citizens call 'bailout' money) to cover premiums of Humana's recently unemployed clients.

I think you should actually try to sue. You seem to object to this kind of statement.

As for the denial of this client's Nexium, I believe Dr. Barczac is wrong.

Nexium is the only drug marketed in the US that is actually approved by the FDA to heal esophageal lesions. Cheap alternatives have not been approved by the FDA. Substituting for Nexium is a gamble on this person's health, and Humana is willing to take that risk. (Remember, Humana assumes no liability for the outcome of the cheap medical treatment). It is always up to the patient and doctor to somehow "scramble" to get the proper treatment initiated.

The $640 billion dollars spent each year on healthcare in this country could go to better use than to fund Dr. Barczac's denials of usual, customary, FDA approved, and effective medical care.

I don't need your help.

Humana needs help.

That is why it is necessary for the US government to infuse money from the taxpayer funded stimulus package (the thing regular citizens call 'bailout' money) to cover premiums of Humana's recently unemployed clients.

I think you should actually try to sue. You seem to object to this kind of statement.

As for the denial of this client's Nexium, I believe Dr. Barczac is wrong.

Nexium is the only drug marketed in the US that is actually approved by the FDA to heal esophageal lesions. Cheap alternatives have not been approved by the FDA. Substituting for Nexium is a gamble on this person's health, and Humana is willing to take that risk. (Remember, Humana assumes no liability for the outcome of the cheap medical treatment). It is always up to the patient and doctor to somehow "scramble" to get the proper treatment initiated.

The $640 billion dollars spent each year on healthcare in this country could go to better use than to fund Dr. Barczac's denials of usual, customary, FDA approved, and effective medical care.

Um, Franzg, I didn't say I was going to sue you... Why would I do that? I'm just saying that alot of what you're saying can get you into legal trouble. I'm just trying to help you out.

Is it misinformation that Humana is receiving premiums from the 2009 economic stimulus package (us citizens refer to this as the "bailout") to cover its recently unemployed clients?

Go ahead and file suit.

The US congress and the US President are also warning us citizens that if our current managed care system is allowed to continue on its present course, we will incur a $54 trillion deficit in the next 5 years. Maybe you should sue them as well.

Go for it, you creep.

Still, Sylvester denied the prescription for 80 mg nexium. Deemed "not medically necessary." 40 mg is OK. I guess 40 mg would be "medically necessary". Dr. Barczak runs an "administrative practice" under his medical license (that means he does not treat patients, folks). That's where your healthcare dollar is going.

This system is dysfunctional, and the managed care companies do not feel it is necessary to cooperate with the patients and physicians. They are quite interested in filing suit, as you can tell from the previous post. More healthcare dollars down the tube. Whoopie!

Managed care is out of control, and is causing harm to our physical and economic health.

Humana is not receiving a bailout. Congrats, Franzg, you've just graduated from being misinformed to outright lying. If you don't like managed care and/or Humana, that's fine, but I'm telling you that if someone in their legal department picks up on these lies you're telling, they can sue you for libel and they will most likely win. Just trying to help you out.

Sorry William, but Humana denied the Nexium. The employer did not.

Please read the posts- Nexium IS on Humana's formulary (or should I say the EMPLOYER'S formulary). Humana deemed the treatment "not medically necessary". Why does everyone else (including the FDA) think Nexium is appropriate for this client except Humana? Is Nexium a "bad drug" or a "ripoff"? Should we blame those who don't object to this client being on Nexium? Why does Humana have a formulary, yet in the next sentence claim our employers are the only ones who have a formulary?

Most likely what happened was that Humana denied Nexium based on price. Humana wants the client to try a "cheap alternative" to Nexium (like there even is one). That is how managed care works- pay for cheap meds, deny modern, safer, more effective ones.

If this client's esophagus ruptures, no doubt Humana would pay for Rolaids and deny the necessary emergency surgery.

Gold and Microsoft are not getting bailed out. Humana is, and continues to tank.

Last I checked, gold's price "slid" to $878 per ounce. Good luck arguing the price of gold is "down".

obviously needs work. Everyone's stock is in the tank right now.

Microsoft is down YTD also, I guess that means they're getting a bailout. Ooooh and Gold is down also, guess we are going to bailout Gold. Show me where any Healthcare company has filed for, received, or was offered a bailout, and I will stand corrected.

Until then, might I suggest you talk to your doctor about adjusting your daily dosage of whatever medication you're currently on.


As for the OP's problem regarding their prescription, there really isn't much anyone at Humana can do. The formulary (the medications that are covered by your plan) are chosen by the group i.e. your employer. Name brand meds like Nexium are 2, 3, sometimes as much as 10x more expensive than generic alternatives. The name brands will often not be covered in the formulary, because it made the plan cheaper for your employer.

I would check with your doc and tell him or her that the med isn't covered in your formulary and ask for alternatives...or you should be able to handle that through Humana.

Sorry, but the taxpayer funded stimulus package (aka "bailout") IS paying the premiums for the recently unemployed Humana clients.

Sorry you are in denial about that.

Humana stock prices continue to tank.

Sorry you are in denial about that.

As for this client, Nexium is approved by the FDA for this condition. Humana just does not want to pay for it.

This client's problem is not due to the physician receiving a "kickback", it is due to Humana's refusal to pay for the ordered medication. The FDA is just fine with the physician order. No "ethics committee" is needed to bust a physician or a drug representative.

Humana just needs to pay for the healthcare they agreed to when they took this client's money.

Sorry you are in denial about that.

have the right to refuse to pay for perscriptions that do not fall within their pre-determined dosage guidelines. What is covered and not is up to them and in your policy. I would call them to see them to see what would be a covered alternative at the dosage you require. Otherwise, they will pay for what they deem necessary to treat you and you will have to come out of pocket for the rest.

have the right to refuse to pay for perscriptions that do not fall within their pre-determined dosage guidelines. What is covered and not is up to them and in your policy. I would call them to see them to see what would be a covered alternative at the dosage you require. Otherwise, they will pay for what they deem necessary to treat you and you will have to come out of pocket for the rest.

have the right to refuse to pay for perscriptions that do not fall within their pre-determined dosage guidelines. What is covered and not is up to them and in your policy. I would call them to see them to see what would be a covered alternative at the dosage you require. Otherwise, they will pay for what they deem necessary to treat you and you will have to come out of pocket for the rest.

have the right to refuse to pay for perscriptions that do not fall within their pre-determined dosage guidelines. What is covered and not is up to them and in your policy. I would call them to see them to see what would be a covered alternative at the dosage you require. Otherwise, they will pay for what they deem necessary to treat you and you will have to come out of pocket for the rest.

AND SOMETHING WILL PROBABLY BE DONE SO THAT IT DOESN'T HAPPEN TO YOU AGAIN.

........Franzg said:

"Humana is now poised to be acquired by Aetna, or poised to perhaps make its own acquisitions. You might want to read the newspaper before you post."

.......You might want to do the same, my friend. You just fell victim to a Wall Street rumor. Pasted below is information from CNN money...

"I don't know why they'd be up other than speculation that Aetna is talking to them in terms of a potential acquisition," Stifel Nicolaus analyst Thomas Carroll said. "It's purely rumor."

Shares of health insurers -- which have been beaten up amid concerns over U.S. healthcare reform -- were up broadly on Friday. Aetna shares were 4.2 percent higher.

A Humana spokesman was not immediately available for comment. An Aetna spokesman said it does not comment on rumors and speculation.


"This is a rumor that many think is feeding on itself. This is a slow day and option traders need something to talk about, especially in light of what has happened in that sector over the past few weeks," said Joe Kinahan, chief derivatives strategist at online brokerage thinkorswim Group in Chicago.

........Here's some more from Business World:

"My sense would be that Humana is not for sale," Carroll said.

The healthcare sector has been an active area for acquisitions lately, potentially stoking speculation.

"Several recent takeover announcements, such as Merck's bid for Schering-Plough , have perked up the interest of many investors who are looking for the next takeover candidate," said William Lefkowitz, options strategist at brokerage firms vFinance Investments in New York.


........In terms of your bailout question, here's a bit from International Business Times (3-24-09):

Humana Inc rose on Monday after the second biggest health insurer in the U.S. unveiled an optimistic forecast for 2009.

Shares of Humana rose 6.3 percent, or $2.40 to $40.33 a share on the New York Stock exchange by 2:25 p.m. Monday.

The Lousville-based group said today it expected earnings in the range of $5.90 to $6.10 per share for the full year 2009. Its forecast is well above the $5.92 per share predicted by analysts, according to Forbes, and significantly bigger than the $3.83 per share it recorded in the full fiscal year 2008.

Humana earned $174.1 million or $1.03 per share in the fourth quarter compared to $243.2 million or $1.43 per share in the same period of 2007. Revenue jumped 18 percent from a year earlier to $7.49 billion.

.........So, what have you learned? Hopefully, it's the fact that rumors exist on the internet, Franzg. God only knows why people start these rumors. But, even if Aetna did purchase Humana, what would change? Nothing. The company policies and procedures would remain exactly the same. The only thing that would change would be the sign on the door.

Franzg, that acquisition you were talking about is just a rumor. If you read forbes.com, you'll see both companies denied the rumor. It's probably someone on Wall Street starting rumors so they can make some quick cash in stocks.

Franzg, even if Aetna buys Humana, that's not going to change anything in terms of compliance with DOI guidelines or practicing policy. First, it's a phantom "bailout by the government" with you and now "Humana is going out of business" because of a proposed merger (which isn't even confirmed yet). You're reaching now.

Billions will go to subsidies to pay premiums Humana would lose to the recently unemployed. It is being funded by our taxpayer funded economic stimulus package (aka Bailout).

Humana is now poised to be acquired by Aetna, or poised to perhaps make its own acquisitions.

You might want to read the newspaper before you post.

As for the consumer, it seems the prescription was already appealed and denied. Another "kickback" thwarted by our Holy Humana?- I think not.

Most likely, another ulcer is in the making, courtesy of managed care stupidity and red tape. Humana "covers" Nexium, but only 1 pill a day. Read your certificate.

The key word here is "price" not "medical necessity". The drug rep was not present when the prescription was written, and the prescribing doctor did not receive a "kickback".

The real reason the prescription was denied was to save a buck for the corporation.

Unfortunately, prescription drugs are expensive. As such, these same drugs tend to have policy limitations on them that require a form of advance approval prior to being paid by insurance.

The magic words are "medical necessity". You, as a patient, have the right to request a prior authorization review for the dosage your doctor is prescribing. What this boils down to is having your doctor contact Humana (a call to customer service will result in getting that information...press "0" at the options, it will forward you to a rep or the hold line for a rep. The quality announcement is a legal necessity and a courtesy to let people know that the calls are recorded, and although it is annoying Humana is far from the only company that does so. Any company that records and reviews their calls will have the same announcement.). He or she can request the medical necessity authorization, and send notes supporting this review. If it is then denied, you have the right to appeal that denial to Humana (or any other major insurance carrier). It's time consuming, yes, but really your end is to write the appeal letter (or ask your prescribing doctor to appeal on your behalf). This will result in a second review, by a different medical director (all of whom are experienced doctors. No company hires med school graduates with placenta still on their face. Remember, they have to be able to show whatever decision they made was based on experience, expertise, and a competent review.) Under the regulations on the insurance industry, the appeal has to be handled completely by people with no connection to your previous denial.

I am sorry this happened to you, and hope it does get resolved. The best way to expand formularies is to reduce the cost of prescription drugs, something most insurance companies are willing and working to do. I'm not going to say I haven't worked in insurance, I have. I believe, though, that a competent review will at least provide you with more concrete answers of what is happening, and possibly resolve the situation completely.

Humana isn't getting a government bailout, Franzg. As for the drug rep situation, fine, live in your little ignorant world. Have fun getting financially raped by your providers.

You can't be serious?

My physician is taking money from a pharmacy representative? That can't be legal.

It also cannot be the reason why Humana denied the prescription. Humana denied it to save money and increase profits.

The above post is an insult to our intelligence. If Humana actually is in business to deny prescriptions because they suspect my physician is trying to "pull something", I think I would probably prefer the FBI to do that, because they are already being paid to do so.

So I guess the Humana client IS the victim in this case. They have no say in the matter, because Humana is now in the business of arbitrarily deciding which physicians are prescribing Nexium for health reasons, and which are trying to "pull something". (see above post).

Lets try this again:

Client: "I'm sick, doctor"

Doctor: "Oh, try this. It has been shown to improve your condition"

Humana: "Me likey money. Me not want to pay. Me need government bailout"

Client: "Guess I'm paying out of my own pocket, again. Guess I'll try to get some info about a plan that WILL cover Nexium"

That is probably what happened to this Humana client who posted on Ripoff report.

Franzg said "I want to know who pays the doctor commisions
Yes, tell me how my doctor makes a commission (I believe you called it a 'kickback') by prescribing my Nexium.

Please explain clearly, and please refrain from referring to everyone else as 'stupid' a 'whiner' or 'greedy'.

Please try to leave your preoccupation with Michael Moore out of it. Please refrain from referring to others as 'communists' and 'quacks' as well.

We are waiting............................................................................"

Ok, Franzg, obviously I don't know who you doctor is (nor do I want to know), so let's just speak in generalities. I'll try to slow it down for you and speak in terms you might understand...

Drug rep say, "Doctor, you sell my drug to customer, I give you dis here money."

Doctor say, "Good. Me likey money."

Drug rep say, "More dis you sell, more money I give."

Doctor say, "I will sell lots. Don't care if customer need it or not."

Drug rep say, "Yay!"

So, could you follow that scenario? I could buy some puppets if you need a visual aid.

Yes, tell me how my doctor makes a commission (I believe you called it a "kickback") by prescribing my Nexium.

Please explain clearly, and please refrain from referring to everyone else as "stupid" a "whiner" or "greedy".

Please try to leave your preoccupation with Michael Moore out of it. Please refrain from referring to others as "communists" and "quacks" as well.

We are waiting............................................................................

What more do you want to know? It's like a salesman getting commissions; you're going to work harder and do whatever you can (ethically or not) to pawn that drug off on people.

What more do you want to know? It's like a salesman getting commissions; you're going to work harder and do whatever you can (ethically or not) to pawn that drug off on people.

How does my physician receive a "kickback" after prescribing Nexium? Are you referring to calendars and pens?

Maybe Humana should issue cute pens and calendars to the physicians so they can have their "kickback". Gee, my doctor does not have enough calendars- prescribe me meds that have a calendar.

I called for a rep for Astra-Zeneca (makers of Nexium), they told me they don't issue calendars or pens to physicians.

The point is, that the physician denying the med made more $$ than the physician prescribing it. Maybe Humana only knows "money grubbing" physicians that "chase the dollar" and want colorful calendars to decorate their offices.

Andromeda, I beg you to quit watching Michael Moore movies. I imagine that you've bought, rented, read, or heard about the Michael Moore movie "Sicko". This grand opportunist and liar has obviously brainwashed you as well. About the lawsuit you're speaking of, please research it on the internet. You'll find the following facts:(this is pasted DIRECTLY FROM WIKIPEDIA)

"Video of Linda Peeno's testimony appeared in Michael Moore's 2007 documentary Sicko. On June 28, 2007, in a statement about the movie, Humana declared that Peeno was never a Humana associate (permanent, full-time employee), but rather a "part-time contractor". Humana also disputed the portions of Congressional testimony that were shown by saying that because the patient's specific healthcare plan didn't cover heart transplants, the denial of coverage was valid."

Valid, sweetie. That means that the employer of that patient didn't want to cover transplants in their policy. It's unfortunate, I agree. Again, what's covered or not in a policy is a decision made by Humana's client, not Humana. How about this example? Catholic hospitals and healthcare systems don't approve of abortions, elective or medically necessary. So if a pregnant woman who works for a Catholic Hospital dies because she doesn't want to pay out of pocket for her medically necessary abortion, I'm sorry, it's not Humana's fault.

While you're online, why don't you do some research on Mr. Moore as well. He has stock in all of those companies he criticizes and much of his data is flat out false. You are falling prey to a guy who just starts controversy so he can get more tickets sold to his one-sided documentaries.

Like I said, do you think the doctor's order all of the colorful calendars, pens, and mousepads? It's a little incentive from drug sales reps. Use your head, the doctors didn't order them. What, do you want me to approach a random doctor and have them mail something to you? This is common knowledge. It's like asking me to prove that the sky is blue. So stuff your "prove it" comment.

Dear I am not the Law.

"Those reps work out a deal with your doctor to give them a kickback every time they prescribe their medication. The more they prescribe, the more the doctor makes."

"The more they prescribe, the more the doctor makes. Suddenly, your health becomes a sales situation for your doctor."

"This person has the same credentials, if not more, than the doctor you just saw. They also take the same oath as a medical doctor since they are a health care provider as well."

"Make no mistake, your doctor is chasing the allmighty dollar as well."

As usual, you shot off your opinion. passing it off as the truth. Acting like you know something.

Proof of the above 4 statements please. Show us your references! No proof, no truth.

Oh, is this the same Humana that killed a hospital patient a few years ago by refusing to cover the medically necessary life saving surgery, and lost the resulting lawsuit?

That's right Humana, refuse to listen to the doctors again! You never learn.

I am waiting for your references. Go get them Big Boy!

I will be here until you produce them!

I've read your report and let fill you in on a little known secret about the wonderful world of prescription medications. Ever notice when you go to the doctor's office, they have a million different colorful pens, calendars, mouse pads, and other gizmos advertising various medications? Believe me, people, your doctor didn't place an order for those things. Nope, they came from pharmacy sales reps. Those reps work out a deal with your doctor to give them a kickback every time they prescribe their medication. The more they prescribe, the more the doctor makes. Suddenly, your health becomes a sales situation for your doctor. So, obviously, when a claim gets presented to your insurance company with an unusually high dosage amount or if a doctor seems to only prescribe expensive medications versus cheaper ones that do the same thing, then yes, you may get a denial from your insurance carrier. In the nutshell, your doctor is probably over-prescribing to line their own pocket.
Anything that goes under a medical review at the insurance company can only legally be reviewed by a medical director. This person has the same credentials, if not more, than the doctor you just saw. They also take the same oath as a medical doctor since they are a health care provider as well. So basically if the medical director thinks that the prescribing doctor is trying to pull something, you run into situations like this. Make no mistake, your doctor is chasing the allmighty dollar as well. Sometimes they're doing it unethically by needlessly prescribing or over-prescribing drugs.
Bill, I'm not agreeing or disagreeing with the decision made by that medical director. I'm just trying to give you some insight on what Humana's rationale might be. I'd suggest calling them for further detail.

I agree with your comment. The denial of this dosage is unfair. It is giving me an ulcer just thinking about it.

The usual adult dose of Nexium is 40 mg per day. If your condition does not improve, or worsens, the dosage may be increased to 80 mg per day maximum.

The insurance companies will claim that 80 mg per day has not been proven in studies to alleviate some conditions better than the 40 mg per day dose. This is based on clinical trials.

What this means, is that 150 out of 200 total subjects did not show that much improvement in their esophageal conditions after increasing the dose from 40 mg per day to 80 mg per day. These subjects were carefully picked for safety reasons- no recent surgeries, no heart conditions, and on no meds that would interfere with the effectiveness of a certain dose of Nexium.

You may be one of the individuals who does very well on the 80 mg per day maximum allowable dose of Nexium. You may weigh 350 lbs. You may be taking a medication, or suffer from a condition that decreases the levels of Nexium in your bloodstream. Maybe you are being treated by an astute physician who is keeping up with case reports which recommend 80 mg per day of Nexium for your condition. Whatever the reason, I'm sure you would rather follow the physician's recommendations than have to suffer through the stupidity of the insurance company.

The good news is that the decision can be appealed. Call and notify your physician immediately, and ask for an expedited appeal, or you may be waiting a long time.