Claims Denied for Prescription Coverage

[cskelley1]

I recently changed employers and hence, changed insurance providers. My initial coverage was denied because I did not maintain coverage from the time I started with the new company and had to wait 30 day before the coverage began. However, after 6 weeks of filing appeals that contained evidence of creditable coverage through the 30-day waiting period I was granted coverage by my new provider.

I was being treated by a doctor that is an approved provider before I changed companies however both insurance companies have the same doctor in their list of Approved Providers. I was receiving a weekly injection (covered by my previous insurance with a $100 co-pay per three month supply) and per the new insurance provider this same prescription is on their list of approved medications with a similar co-payment/supply ratio but only provided in one month doses. Me prescription was low and I went to get my remaining refill (3-month supply) and was denied by my new insurance provider - not because it was a 3-month supply but because I had not been on another (less expensive) form of treatment for six months and had problems with it. I went through this same problem with my old insurance company three years ago when I was first diagnosed with my condition but after several failed treatments and a rapidly worsening condition, the previous insurance company began paying for my prescription that prevent my condition from getting worse and handles any associated pain that I may experience.

How can they all of a sudden require me to go back through failed treatments to prove that they don't work before they will consider paying for the prescription that has been the only thing that worked in 5 years? What about my health in the meantime? Am I supposed to just suffer through it until they decide they will pay or not pay? My prescription without insurance runs approx. $1700/month - which I can not afford without the aid of insurance. The interesting thing about it all is that my previous provider was Blue Cross Blue Shield of Illinois and my new provider is Blue Cross Blue Shield of Alabama! What do I do? Can I do anything? Please help because I am already out of my medication and I am starting to feel the effects - I suspect that I will be unable to walk within the next 60 days.

[lealea1005]

Blue Cross Illinois and Blue Cross Alabama are two different insurance companies. You have a different insurance policy and a different pharmacy plan.

Each pharmacy plan has their own authorization requirements. They are not saying you cannot be treated with the medication you prefer, they are stating they will not pay for that medication without documentation that you have failed previous therapy on the medication covered by the plan. Has your Physician submitted documentation of your previous failure on the substitute medication?

[SBillock]

I agree with LeaLea. Get documentation from your physician showing you have already tried the substitue medication and it failed hence the reason you are using the other is not personal preference but a necessity.

[cskelley1]

I neglected to include that my Physician has already submitted my treatment history three times and it has been rejected by BCBS Alabama each time. If they both accept the same doctor in their networks and they both say they will cover this specific prescription then why are they denying my claim. My doctor has been extremely helpful with this matter and has all but assigned someone to just work on this with my insurance company. She has even offered to give me samples of the medication to help me out until something is worked out with the insurance company but I know her generousity and concern can only continue for so long. Any suggestions?

[ecmst12]

They're denying it because you haven't met their requirements for coverage. You have to go through the 6 month trial with the other medication before they will approve coverage for this one.

[momm2500]

Appeal higher up at the Blues. My suggestion is get the name of the President and send a copy of all your documentation and send it to him/her. Followup within 2 weeks and speak to them or their assistant. Explain the situation that you have previously had blues with another state and now have blues with Alabama. I would suggest you also ask to speak with a case manager at the Blues. That would be a nurse who can understand all the paperwork from the doctor. It can be time consuming but you can at least get a couple of different eyes to look at everything.

[cskelley1]

Originally Posted by ecmst12

They're denying it because you haven't met their requirements for coverage. You have to go through the 6 month trial with the other medication before they will approve coverage for this one.

So even if I have already done this and had negative effects from it I have to go through it again (potentially making my condition or overall health worse) just to "maybe" get it approved? I went through this whole thing three years ago with BCBS Illinois. Is it legal to jeopardize someone's health in that way?

[cbg]

To all intents and purposes, there are 50 different BCBS's - one for every state. They have different plans and different rules and different data bases. It's as different going from BCBS of one state to BCBS to another, as going from United Health Care to Aetna.

The law does not say that different insurance companies have to violate their own rules. How do they know what you've already gone through?

You can ask your doctor to send them a letter explaining your history and see if they will make an exception, but they are not required to and the law is not going to force them to. They may, they may not. It is not illegal if they do not.

What people do not seem to realize is that an insurance policy is not mandated to pay whatever the doctor deems medically necessary. It is not a guarantee of payment for anything and everything the doctor wants or even that the patient needs. The policy is a contract that says, essentially, we will pay for x when y happens. If y does not happen, they are not required to pay for x. If the policy is written to say that they will only pay x if y happens, then you have to try y before they will pay for x. They are not obligated to accept, "oh, I did that once before and it didn't work".

Whether or not they will accept your having tried y when you were covered under someone else's policy is pretty much up to them.

[lkc15507]

Originally Posted by lkc15507

What people do not seem to realize is that an insurance policy is not mandated to pay whatever the doctor deems medically necessary. It is not a guarantee of payment for anything and everything the doctor wants or even that the patient needs. The policy is a contract that says, essentially, we will pay for x when y happens. If y does not happen, they are not required to pay for x. If the policy is written to say that they will only pay x if y happens, then you have to try y before they will pay for x. They are not obligated to accept, "oh, I did that once before and it didn't work".

Whether or not they will accept your having tried y when you were covered under someone else's policy is pretty much up to them.

WOW. Lift hat to cbg, applaud loudly for cbg. (tongue in cheek, I'm a parrot)

Folks, ya'll gotta get a grip. Paying a premium doesn't entitle you to whatever you want. READ, READ your plan documents. lkc15507[/quote]

[ecmst12]

So you went through a full 6 month trial with the other medication, and your doctor submitted the records proving it, and they still won't approve it?

[lealea1005]

Originally Posted by ecmst12

So you went through a full 6 month trial with the other medication, and your doctor submitted the records proving it, and they still won't approve it?

I just went through this with a patient and it's frustrating on all sides. There are some meds that just aren't covered by certain insurance plans...no how....no way....you can submit all the documentation in the world, the patient can trial an alternative for a period of time, the Doc can speak with the company's medical director, to no avail because the med just plain isn't on plan. Period. Even if.

As I said earlier...they're not saying you can't take the medication, they're just saying they won't pay for it.

People also have to stop assuming that Blue Cross is the same company with the same policies nationwide. The consumer is responsible for reading/knowing their own policy. If there are questions, call the insurance company for clarification and document their response.

O/T: Have a great holiday weekend everyone!

[cbg]

And don't think I'm unsympathetic to the cause here. My husband takes four different medications daily, two of which cost next to nothing but two of which are quite expensive, costing hundreds of dollars apiece - and our insurance policy has NO Rx coverage. None. Nada. Zip. The entire cost of all four prescriptions is on us.

But that doesn't mean that we can expect the insurance carrier to violate their own rules and pay for something that is not covered. People have a very mistaken idea about insurance coverage. They think that the insurance policy is supposed to pay for anything the doctor wants to prescribe, be it a treatment, a drug, a session in the hospital, or what, and that's just not true.

They are responsible for paying for what the policy says they will pay for, under the conditions that the policy says they will pay it. Nothing more. Nothing less.

[cskelley1]

Originally Posted by ecmst12

So you went through a full 6 month trial with the other medication, and your doctor submitted the records proving it, and they still won't approve it?

Yes, I went through the recommended trial and my doctor provided all of these results to the new insurance company. Ecmst12, thank you for your interest in my situation.

In response to those other posters who would like to suggest that "people" don't read their plan documents, how do you think I knew that my new insurance company will pay for this med? It is listed on their preferred drug list which is in the plan documents. I checked that before I even applied for coverage. Also, I was initially denied coverage based on information that was provided by my previous insurance company. My only reason for pointing out that they were both BCBS was to highlight the fact that my information was already being shared so why wouldn't they have shared everything, especially the fact that I had already been through the medications that they were proposing. Not that they are the same company - that was not and is not the issue.

My concern was not that they wouldn't pay for "whatever medication I wanted", because trust me, I don't enjoy taking an injection every week. I would not and did not choose this medication and my Doctor did not just pick the most expensive medication available. I went through YEARS of testing and medication trials and this was the one that worked. I was subjected to all kinds of side effects - many of which I am still dealing with - because of the first insurance company forced trials.

I started this thread to get a better understanding about the legal issues surrounding FORCED drug trials, not to be berated by people who for whatever reason thing that everyone who questions the practices of insurance companies is out to get something for nothing or expect more than what is clearly detailed in the Summary Plan Descriptions and other supporting plan documents.

For those posters that have provided constructive suggestions and insight - I thank you. For the others, get over yourselves.

[lkc15507]

You know what? I am going to apologize that I was a little narrow minded wtih my reply. However, I will refer to poster's last paragraph asking "how can they do this". So, this time, rather than being tongue in cheek, I will reply that they can. They can because it is a contract. A contract that they (the insurer) writes to be applicable to all participants of the plan equally. Premiums and all benefits are determined by the insurer based upon the information they have at hand vs. their plan design. I'm not sure anyone suggests that the med you are on is not the proper one, however, your insurer needs documentation of that as opposed to indignation. Maybe I'm wrong, maybe I missed something, but it seems that your response is full of indignation and no attempts at solution other than ranting at the insurer. So, the answer to your last questions is to seek further information from your insurer about how they may make an allowance for your situation. lkc15507

[ecmst12]

If you have met their stated requirements and they still won't approve it, I think you need to start appealing up the chain. Have you talked to the precert rep? Precert supervisor?