Anyone work for BCBS/LA insurance? Help!
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Anyone work for BCBS/LA insurance? Help!
Posted by drunkenpunkin on 5/23 at 6:57 am
I'm posting this in hopes that one of y'all might be able to help me. My son has a rare condition, just diagnosed in Jan. He was started on the only treatment available, a "cocktail" of high dose supplements which we had compounded out of state to cover all components and minimize the number of pills he needed a day. I had it refilled last month, but 2 wks ago, his doctor sent 2 new components to the pharmacy to be compounded with the others. The pharmacy called to tell me BCBS no longer covers compounded meds. I called BCBS to see what we would have to do to appeal and was told we have to buy the compound out of pocket before we can appeal and before they will accept a letter of medical necessity. Has anyone ever heard of this? My son has only been on treatment for a few months, and it made him very sick at first, but he was just beginning to improve. The lady at BCBS was very rude and refused to let me speak to anyone else, saying everyone else has the same computer system and she was telling me what it said. She said, "You'll have to get your doctor to prescribe something that's covered." I told her there is no other treatment for his condition, and she said "Well, I guess you're just going to have to buy it then, aren't you?"

Does anyone know of someone else I can call that might be able to help me? I can't afford his meds out of pocket. Not even one month. We are trying other avenues (assistance programs for kids like him) but they are all temporary. His doctor has called/faxed/emailed and has just been ignored. He's 8 years old. As his disease progresses, they will pay for things to keep him alive. But they won't pay for the meds that will prevent/prolong that from happening. I don't get it. Any advice appreciated.



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Posted by tiger91 on 5/23 at 7:21 am to drunkenpunkin
I would somehow at least try to get a manager at BCBS. We purchased our policy through an independent agent -- perhaps you did too and that agent can at least get through to a manager for you?

Can the doctor's office call and speak to their medical director if they won't accept a letter of necessity?

Maybe keep calling BC (I know it's a pain in the ass) but perhaps you'll end up with someone who can at least not be rude ... I've had to call and deal with them lately and it's been an actual "pleasant" experience.

Good luck ... having an ill child is hard enough. Having to deal with insurance shouldn't be this hard.

(One last thought ... can maybe the pharmacy somehow help out? Discounts? Donations? Working with MD and insurance together?)



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Posted by BR Tiger on 5/23 at 7:24 am to drunkenpunkin
Alison Young in the corporate office is the VP who the customer relations folks report to. Don't have a number. She isn't the one who makes medical determinations, but I bet she would be interested to hear your experience and would be able to get you to the right person.


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Posted by tiger91 on 5/23 at 7:25 am to BR Tiger
And I would DEFINITLEY tell her about the rude service agent's comments. That's just wrong. "Find a different medicine". Some cases yes but in this one it sounds like kiss my arse would be what I would want to tell her!

This post was edited on 5/23 at 7:26 am

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Posted by Cracker on 5/23 at 7:26 am to drunkenpunkin
Are you calling express scripts ? Or bcbs/LA


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Posted by BR Tiger on 5/23 at 7:31 am to BR Tiger
And I've never heard of having to pay out of pocket as a prerequisite to appeal a denial. Maybe having to pay out of pocket because the appeals process is ongoing and it's the only way to get the meds.

Only thing I can think is they want evidence this is going to work before they pay for it, which still doesn't sound right.

Disclaimer: my experience with this is predominately in an inpatient setting a opposed to outpatient. Also, you are likely talking to someone different than your MD office staff would be.

A thought- maybe call and ask if BCBS has a social worker you can talk to. I know the Medicare advantage plans have social workers whose job it is to assist patients in working through these types of situations.



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Posted by CurDog on 5/23 at 7:33 am to drunkenpunkin
i can ask my wife, she doesn't work for blue cross but one of their competitors.



oh and to add


thanks obama (this time i think this really is the case)



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Posted by VeniVidiVici on 5/23 at 7:35 am to drunkenpunkin
My wife worked as a case manager there for 6 years, and her best friend is a case manager supervisor there now.

I've sent her your post and will let you know any suggestions she may have.

Prayers to the kiddo



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Posted by VeniVidiVici on 5/23 at 7:38 am to drunkenpunkin
This from my wife. Still awaiting reply from current BCBSLA employee

Tell her when she calls BCBS she wants to be connected with a Case Manager. A case manager can then walk her through the next steps.

She can appeal a non-covered benefit through an administrative appeal, everyone has appeal rights. Usually all it takes a formal letter from the member saying they want to appeal and getting their doctor involved as well. The doctor can actually request a peer to peer talk with BCBSLA medical directors and have a discussion about the issue as well.

ETA:

I would also ask to speak to the supervisor in customer service and give her a piece of my mind about her employees customer service. Every call is recorded and they can pull up that encounter and listen to the call. That’s unacceptable.


This post was edited on 5/23 at 7:40 am

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Posted by drunkenpunkin on 5/23 at 8:03 am to BR Tiger
Thank you! Do you know if she is local? Like if I call a local office will someone maybe be able to put me in touch with her?


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Posted by BR Tiger on 5/23 at 8:04 am to drunkenpunkin
She is in the corporate office here in Baton Rouge.


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Posted by tiger91 on 5/23 at 8:06 am to drunkenpunkin
The OT comes through again ... THIS is why I keep telling my husband that the OT is NOT a waste of time!!! At least sometimes ...


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Posted by drunkenpunkin on 5/23 at 8:13 am to VeniVidiVici
Thank you all! Driving to work (hour away). But I will check back in. I can't thank y'all enough. My email: tdpunkin@gmail.com if anyone needs it. I appreciate y'all SO much!


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Posted by HTOWNTIGER1 on 5/23 at 8:27 am to drunkenpunkin
I had a similar situation when my youngest son was born, but it wasn't with BCBS. They would not cover the prescription for a special formula he needed. After fighting with them for several weeks I found out that it could be covered under the "durable goods" part of the policy. As soon as I talked to someone who worked in the durable goods area it was covered. Hopefully it will be the same for you. Good luck!


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Posted by supadave3 on 5/23 at 8:30 am to drunkenpunkin
You know, its threads like this that remind me that my problems are truly not that significant and I need to quite being a little bitch sometimes.

My thoughts are with you drunken. I hope everything works out for you and your little boy.



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Posted by drunkenpunkin on 5/23 at 8:39 am to supadave3
Thanks, sups. You've met my boy before, I believe.


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Posted by MSMHater on 5/23 at 8:52 am to drunkenpunkin
ask the physicians office who the sales rep is, either for the drug itself, or for the compounding pharmacy you use. contact them (preferably drug rep) or ask the office manager to arrange a meeting. tell him/her everything. most of them will have financial assistance programs that will get you through until the letter of medical necessity is approved. and they will still help to a degree even if the letter is not approved. they want you to use the product , even if you can't pay for all of it first. Their hope is they help you for a while and then insurance will pick it up. otherwise...they make nothing.

we do in office infusions for the practice I manage. The drug makers are more than willing to help in the short term. ask them for it.

good luck.



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Posted by TigerTattle on 5/23 at 8:57 am to drunkenpunkin
quote:

The lady at BCBS was very rude and refused to let me speak to anyone else, saying everyone else has the same computer system and she was telling me what it said. She said, "You'll have to get your doctor to prescribe something that's covered." I told her there is no other treatment for his condition, and she said "Well, I guess you're just going to have to buy it then, aren't you?"
Sounds like you got the same B I got when I called, just hateful and uncaring. I wanted to speak to a supervisor and was denied---I thought it was because I told her she was being rude and unhelpful. All I wanted was a question answered (not bill related).

Now, yesterday, for the first time EVER, I receive a bill because BC/BS denied coverage of a regular, everyday medical treatment. Makes me wonder if the B flagged my name. So I've got to call BC/BS again.

I don't really know who else to call, except maybe the insurance commissioner office for advice. Or maybe the State Rep can put us in touch with someone higher up the ladder at BC/BS.

quote:

As his disease progresses, they will pay for things to keep him alive. But they won't pay for the meds that will prevent/prolong that from happening. I don't get it


This is horrible, and I'm very afraid Obamacare is going to make situations like this more common. Prayers that you get the help you need for your son.




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Posted by supadave3 on 5/23 at 8:58 am to drunkenpunkin
quote:

Thanks, sups. You've met my boy before, I believe.


Holy shit, I just realized who you are. Damn, long time no chat. Yeah, I briefly met one of your sons before, I believe it was the oldest one.



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Posted by iluvdatiger on 5/23 at 9:26 am to drunkenpunkin
Jan 1 BCBS went to an evidence based formulary. A lot of drugs moved from a cat 1 (usually $10) copay to a cat 4 ($100) due to there being a generic equivalent available. A lot of cat 4 drugs are now no longer covered. People who were getting these rx's prior to jan 1 were grandfathered in until a future date. For most people that date is june 1 and then they too will be cut off. You can log on to bcbsla site and register as a member. There you should be able to search for equivalents to the drug that is no longer covered. If there is not one, your dr needs to make a prescription drug appeal to bcbs. Also, if this is a group plan, your company should have a broker that they use to help solve member issues with all of the insurance your company offers. That is what I do. We are having lots of issues right now with this evidence based formulary crap. Especially with ADD drugs not being covered. Last week, I had an employee call and said his wife was cut off from neupogen. There is no alternative to it and the actual cost of the drugs is over $1000! It's a bunch of bs and a hot mess.


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