Guest guest Posted April 5, 2008 Report Share Posted April 5, 2008 (and I get 6 vials of Xolair every month!) I have posted I get 6 vials a minth a while back and the quandary behind it. BCBS said 6 vials is fine, option care said no. It is still occurring. I too work for a muncipal pyle456 <coachmac@...> wrote: We're on the state employees health plan, which is with BCBS of NC. They no longer have an " indemnity " plan - now there are three different PPO type plans, with $$copays and such dependent on the amount of premium you pay. Knock on wood there have been no issues with my Xolair coverage. I expect this may due to the fact that we are in a plan that covers tens of thousands of people (if not hundreds of thousands), and the state is able to negotiate really good coverage for even the most expensive drugs and procedures. I pay the same monthly copay that I pay for my blood pressure medicine - $50. (and I get 6 vials of Xolair every month!) Absolutely anyone who is denied Xolair by their insurance company should fight it all the way. --------------------------------- You rock. That's why Blockbuster's offering you one month of Blockbuster Total Access, No Cost. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 5, 2008 Report Share Posted April 5, 2008 My dosage is 3 vials every two weeks. Our BCBS PPO bills Xolair as a drug, so I pay the same monthly copay for Xolair as for any other tier 3 drug. Thank God. > We're on the state employees health plan, which is with BCBS of NC. > They no longer have an " indemnity " plan - now there are three different > PPO type plans, with $$copays and such dependent on the amount of > premium you pay. > > Knock on wood there have been no issues with my Xolair coverage. I > expect this may due to the fact that we are in a plan that covers tens > of thousands of people (if not hundreds of thousands), and the state is > able to negotiate really good coverage for even the most expensive > drugs and procedures. I pay the same monthly copay that I pay for my > blood pressure medicine - $50. (and I get 6 vials of Xolair every > month!) > > Absolutely anyone who is denied Xolair by their insurance company > should fight it all the way. > > > > > > > --------------------------------- > You rock. That's why Blockbuster's offering you one month of Blockbuster Total Access, No Cost. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 6, 2008 Report Share Posted April 6, 2008 When I had Aetna I used to pay $40 per month. Now I'm paying $1,150, sigh. Perhaps the strongest part of my case is Humana and Aetna paid for Xolair with very few questions asked, which brings up the question of did BCBS " fail to exercise the level of care that a prudent managed care organization in similar circumstance would exercise to avoid causing foreseeable injury to their members? " The answer is clearly, yes. pyle456 <coachmac@...> wrote: My dosage is 3 vials every two weeks. Our BCBS PPO bills Xolair as a drug, so I pay the same monthly copay for Xolair as for any other tier 3 drug. Thank God. > We're on the state employees health plan, which is with BCBS of NC. > They no longer have an " indemnity " plan - now there are three different > PPO type plans, with $$copays and such dependent on the amount of > premium you pay. > > Knock on wood there have been no issues with my Xolair coverage. I > expect this may due to the fact that we are in a plan that covers tens > of thousands of people (if not hundreds of thousands), and the state is > able to negotiate really good coverage for even the most expensive > drugs and procedures. I pay the same monthly copay that I pay for my > blood pressure medicine - $50. (and I get 6 vials of Xolair every > month!) > > Absolutely anyone who is denied Xolair by their insurance company > should fight it all the way. > > > > > > > --------------------------------- > You rock. That's why Blockbuster's offering you one month of Blockbuster Total Access, No Cost. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 6, 2008 Report Share Posted April 6, 2008 Absolutely. And that needs to be language included in any demand letter sent by your attorney or any docs filed as part of a lawsuit if it comes to that. > > We're on the state employees health plan, which is with > BCBS of NC. > > They no longer have an " indemnity " plan - now there are three > different > > PPO type plans, with $$copays and such dependent on the amount of > > premium you pay. > > > > Knock on wood there have been no issues with my Xolair coverage. I > > expect this may due to the fact that we are in a plan that covers > tens > > of thousands of people (if not hundreds of thousands), and the > state is > > able to negotiate really good coverage for even the most expensive > > drugs and procedures. I pay the same monthly copay that I pay for > my > > blood pressure medicine - $50. (and I get 6 vials of Xolair every > > month!) > > > > Absolutely anyone who is denied Xolair by their insurance company > > should fight it all the way. > > > > > > > > > > > > > > --------------------------------- > > You rock. That's why Blockbuster's offering you one month of > Blockbuster Total Access, No Cost. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 7, 2008 Report Share Posted April 7, 2008 You are correct about government sponsered health insurance. The contracts that a government agency might negotiate is differenct from one entity to another, and thus, not all are great, but the insurance companies don't screw around with issues such as prior health issues which may eliminate one from coverage. I jumped two years ago from Kaiser to Blue Cross right when I began diagnosis for Eosinophilic Esophagitis without trouble. The only down side is that I pay more for medications whether part of a " pharmacy plan " or " medical plan " . My goal is to get back off of Xolair at some point this year. While it has helped with my mysterious allergic condition, I hate the idea of being tied to it, both monetarily and geographically. ----- Original Message ---- From: pyle456 <coachmac@...> Sent: Saturday, April 5, 2008 4:21:52 AM Subject: [ ] Blue Cross(es) We're on the state employees health plan, which is with BCBS of NC. They no longer have an " indemnity " plan - now there are three different PPO type plans, with $$copays and such dependent on the amount of premium you pay. Knock on wood there have been no issues with my Xolair coverage. I expect this may due to the fact that we are in a plan that covers tens of thousands of people (if not hundreds of thousands), and the state is able to negotiate really good coverage for even the most expensive drugs and procedures. I pay the same monthly copay that I pay for my blood pressure medicine - $50. (and I get 6 vials of Xolair every month!) Absolutely anyone who is denied Xolair by their insurance company should fight it all the way. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 7, 2008 Report Share Posted April 7, 2008 Moderator: I hit the send button too soon before I finished the word " assistance " at the end of the post. Perhaps you'd better send this response instead. Oops! I hate the idea of being tied to it, both monetarily and geographically. ------>>> I just couldn't agree more with this part but unfortunately, the cheaper, more accessible drugs don't work like Xolair. I'm currently working with SPOC (they changed their name - can't recall it offhand) to see if they can convince BCBS they are making a mistake. In lieu of that, I may qualify for financial assistance. Larson <cajjz109@...> wrote: You are correct about government sponsered health insurance. The contracts that a government agency might negotiate is differenct from one entity to another, and thus, not all are great, but the insurance companies don't screw around with issues such as prior health issues which may eliminate one from coverage. I jumped two years ago from Kaiser to Blue Cross right when I began diagnosis for Eosinophilic Esophagitis without trouble. The only down side is that I pay more for medications whether part of a " pharmacy plan " or " medical plan " . My goal is to get back off of Xolair at some point this year. While it has helped with my mysterious allergic condition, I hate the idea of being tied to it, both monetarily and geographically. ----- Original Message ---- From: pyle456 <coachmac@...> Sent: Saturday, April 5, 2008 4:21:52 AM Subject: [ ] Blue Cross(es) We're on the state employees health plan, which is with BCBS of NC. They no longer have an " indemnity " plan - now there are three different PPO type plans, with $$copays and such dependent on the amount of premium you pay. Knock on wood there have been no issues with my Xolair coverage. I expect this may due to the fact that we are in a plan that covers tens of thousands of people (if not hundreds of thousands), and the state is able to negotiate really good coverage for even the most expensive drugs and procedures. I pay the same monthly copay that I pay for my blood pressure medicine - $50. (and I get 6 vials of Xolair every month!) Absolutely anyone who is denied Xolair by their insurance company should fight it all the way. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 7, 2008 Report Share Posted April 7, 2008 What size employer do you work for? That may be part of the issue - that you work for a smaller employer who cannot leverage the kind of coverage a government plan can. Addy > > We're on the state employees health plan, which is with > BCBS of NC. > > They no longer have an " indemnity " plan - now there are three > different > > PPO type plans, with $$copays and such dependent on the amount of > > premium you pay. > > > > Knock on wood there have been no issues with my Xolair coverage. I > > expect this may due to the fact that we are in a plan that covers > tens > > of thousands of people (if not hundreds of thousands), and the > state is > > able to negotiate really good coverage for even the most expensive > > drugs and procedures. I pay the same monthly copay that I pay for > my > > blood pressure medicine - $50. (and I get 6 vials of Xolair every > > month!) > > > > Absolutely anyone who is denied Xolair by their insurance company > > should fight it all the way. > > > > > > > > > > > > > > --------------------------------- > > You rock. That's why Blockbuster's offering you one month of > Blockbuster Total Access, No Cost. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 9, 2008 Report Share Posted April 9, 2008 I'm self-employed so I'm covered on my wife's plan. They have about 20 people in the company so it's a fairly small sized place. We were insured through Humana and Aetna through the same company and I had no problem with the Xolair coverage. BCBS isn't taking issue with that. They are suggesting it doesn't work so there is no need to continue the therapy. You know why I really think they are denying this....if you dig through my posts from last fall I posted that Xolair had stopped working, which it did. It worked for about 3-4 days, which would be followed by intense itching. I thought perhaps my IgE levels had climbed so I stopped taking it for 1 month and went and had it retested and it came back essentially the same. Once I started back on the shots I returned to normal - very stable. It's my belief - naturally I can't prove this - that BCBS read what I wrote and denied it immediately so they could request my doctors records, which states the same thing that I just mentioned. I've been doing a lot of research on Denial of Benefits cases and insurance companies are now going to places like myspace and gathering information from private emails to use against their subscribers when they file insurance claims so it's highly likely that I got turned down because of what I posted on this board. Be careful what you post from now on. This is going to be an expensive lesson for me but fortunately the law is on my side. pyle456 <coachmac@...> wrote: What size employer do you work for? That may be part of the issue - that you work for a smaller employer who cannot leverage the kind of coverage a government plan can. Addy > > We're on the state employees health plan, which is with > BCBS of NC. > > They no longer have an " indemnity " plan - now there are three > different > > PPO type plans, with $$copays and such dependent on the amount of > > premium you pay. > > > > Knock on wood there have been no issues with my Xolair coverage. I > > expect this may due to the fact that we are in a plan that covers > tens > > of thousands of people (if not hundreds of thousands), and the > state is > > able to negotiate really good coverage for even the most expensive > > drugs and procedures. I pay the same monthly copay that I pay for > my > > blood pressure medicine - $50. (and I get 6 vials of Xolair every > > month!) > > > > Absolutely anyone who is denied Xolair by their insurance company > > should fight it all the way. > > > > > > > > > > > > > > --------------------------------- > > You rock. That's why Blockbuster's offering you one month of > Blockbuster Total Access, No Cost. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 9, 2008 Report Share Posted April 9, 2008 << They are suggesting it doesn't work so there is no need to continue the therapy. > << I thought perhaps my IgE levels had climbed so I stopped taking it for 1 month and went and had it retested and it came back essentially the same. Once I started back on the shots I returned to normal - very stable. It's my belief - naturally I can't prove this - that BCBS read what I wrote and denied it immediately so they could request my doctors records, which states the same thing that I just mentioned.>> , I think you have solved the problem. An expensive drug??? You bet they re going to look through your medical records. They saw that it didn't work for that short time and THAT gave them a case to deny it. No, you yourself can't prove this but a good lawyer can. It is highly doubtful that they would use info off of an internet board to make judgments about your health and a claim. We are not professionals here, just patients like you. Insurance wants wants REAL medical records to make their decisions. Fight the good fight my friend. We are all pulling for you!!! Doug Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 10, 2008 Report Share Posted April 10, 2008 , It would not surprise me if insurance companies are trying to mine the internet for information on their patience, particularly using services like myspace. None of that information is protected under HIPAA, so they are free to search at will. I think something that all of us need to take into account is that Xolair cannot bind to ALL of our IgE and that we are continually making new, unbound IgE so our symptoms may recur at any time. This does not mean Xolair isn't working, simply that our systems are manufacturing new IgE which is just waiting for an allergen to get to it before Xolair does! Please keep us posted on the good fight! Addy Group co-owner > > > We're on the state employees health plan, which is > with > > BCBS of NC. > > > They no longer have an " indemnity " plan - now there are three > > different > > > PPO type plans, with $$copays and such dependent on the amount > of > > > premium you pay. > > > > > > Knock on wood there have been no issues with my Xolair coverage. > I > > > expect this may due to the fact that we are in a plan that > covers > > tens > > > of thousands of people (if not hundreds of thousands), and the > > state is > > > able to negotiate really good coverage for even the most > expensive > > > drugs and procedures. I pay the same monthly copay that I pay > for > > my > > > blood pressure medicine - $50. (and I get 6 vials of Xolair > every > > > month!) > > > > > > Absolutely anyone who is denied Xolair by their insurance > company > > > should fight it all the way. > > > > > > > > > > > > > > > > > > > > > --------------------------------- > > > You rock. That's why Blockbuster's offering you one month of > > Blockbuster Total Access, No Cost. > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 11, 2008 Report Share Posted April 11, 2008 Addy, Here is a website I found that suggests insurance companies are actively searching the internet for ways to deny benefits: http://attorneypages.com/hot/blue-shield-deny-policy-over-private-email.htm I don't want to scare anyone off when it comes to discussing your asthma on this message board because it's an incredibly useful resource but just keep this in the back of your mind. It seems most folks are logged in under an alias, which is good, but I couldn't find a way to change my name that appears so BCBS had full access to what I was posting, if they were looking. At any rate, the same information is in my medical file so I don't think any harm was done here. Switching gears.....I went 6 days without my Xolair shot because I ran out and was hoping I could actually stop taking it, or at least postpone it. On the 6th day I found myself on Prednisone. I got my shot on Wednesday but I'm fighting a tough game of catch up. I suspect it will take a while for the Xolair to catch up to the excess IgE I have probably generated during the 6 days. Lots of storms passing thru the area too so that's not helping -- sigh, pant. My doctor said he is writing another letter to BCBS in response to their last denial. I doubt it will help. I think the only thing that will convince them I need to stay on this shot is a hospital visit. I carry my epi-pen with me all the time right now. pyle456 <coachmac@...> wrote: , It would not surprise me if insurance companies are trying to mine the internet for information on their patience, particularly using services like myspace. None of that information is protected under HIPAA, so they are free to search at will. I think something that all of us need to take into account is that Xolair cannot bind to ALL of our IgE and that we are continually making new, unbound IgE so our symptoms may recur at any time. This does not mean Xolair isn't working, simply that our systems are manufacturing new IgE which is just waiting for an allergen to get to it before Xolair does! Please keep us posted on the good fight! Addy Group co-owner > > > We're on the state employees health plan, which is > with > > BCBS of NC. > > > They no longer have an " indemnity " plan - now there are three > > different > > > PPO type plans, with $$copays and such dependent on the amount > of > > > premium you pay. > > > > > > Knock on wood there have been no issues with my Xolair coverage. > I > > > expect this may due to the fact that we are in a plan that > covers > > tens > > > of thousands of people (if not hundreds of thousands), and the > > state is > > > able to negotiate really good coverage for even the most > expensive > > > drugs and procedures. I pay the same monthly copay that I pay > for > > my > > > blood pressure medicine - $50. (and I get 6 vials of Xolair > every > > > month!) > > > > > > Absolutely anyone who is denied Xolair by their insurance > company > > > should fight it all the way. > > > > > > > > > > > > > > > > > > > > > --------------------------------- > > > You rock. That's why Blockbuster's offering you one month of > > Blockbuster Total Access, No Cost. > > > > > > Quote Link to comment Share on other sites More sharing options...
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