problems with BCBS reauthorization

[Guest guest]

Hello, all,

A little over a month ago, my Xolair script was due for

reauthorization. Medco, BCBS of NC pharmacy provider, denied it as

being non-medically necessary b/c I didn't have a qualifying IgE

score (despite the fact that I, of course, do). So I had to initiate

the appeals process. A couple of weeks ago, I faxed a letter to

my " appeals analyst, " after I got a letter giving me her name and

contact info. I detailed the problem AGAIN, blah, blah. Shortly

thereafter I had a terrible allergic episode requiring pred and

antibiotics. I'm still on pred. Tuesday I faxed her (after phoning,

she was out of the office that day), explaining that I was on pred

and my symptoms were increasing and my condition deteriorating. I

faxed again the next day, called yesterday, called again this morning

and said, " please let me know something by the end of the day. "

Well, she called at 4:30pm and said she had gotten the medical

director to approve me to get a month's worth of Xolair until they

figure out what the heck they are doing. (my words, of course). I

called Accredo, they promised to call BCBS Monday am and get my drugs

shipped in time to arrive before the holiday.

So, my recommendation is to squeak often, politely, and let them know

EXACTLY HOW MISERABLE YOU ARE.

Addy

[Guest guest]

--- In , " pyle456 " <jamcculloch2@...>

wrote:

>

> Hello, all,

>

> A little over a month ago, my Xolair script was due for

> reauthorization. Medco, BCBS of NC pharmacy provider, denied it as

> being non-medically necessary b/c I didn't have a qualifying IgE

> score (despite the fact that I, of course, do). So I had to

initiate

> the appeals process. A couple of weeks ago, I faxed a letter to

> my " appeals analyst, " after I got a letter giving me her name and

> contact info. I detailed the problem AGAIN, blah, blah. Shortly

> thereafter I had a terrible allergic episode requiring pred and

> antibiotics. I'm still on pred. Tuesday I faxed her (after

phoning,

> she was out of the office that day), explaining that I was on pred

> and my symptoms were increasing and my condition deteriorating. I

> faxed again the next day, called yesterday, called again this

morning

> and said, " please let me know something by the end of the day. "

>

> Well, she called at 4:30pm and said she had gotten the medical

> director to approve me to get a month's worth of Xolair until they

> figure out what the heck they are doing. (my words, of course). I

> called Accredo, they promised to call BCBS Monday am and get my

drugs

> shipped in time to arrive before the holiday.

>

> So, my recommendation is to squeak often, politely, and let them

know

> EXACTLY HOW MISERABLE YOU ARE.

>

> Addy

>

Sounds all too familiar. On July 24, 2008, I was due to renew my

Xolair. The Insurance Company, Oxford, denied it, of course. " Not

medically ncessary. " I appealed and they replied, " Need doctor's

notes, " (they wait until you need you medicine!). This was the second

time they had done that to me (it was about a month of interruption

the first time). But, ths time, when they recived the doctor's notes,

they replied (after 2 weeks!), " Doctor's notes illegible, " I too

begged and pleaded that my condition was deteriorating, but no one

cared.The doctor's assistant typed the notes and I waited another 2

weeks. All total: 2 months had passed without Xolair. I have a

secondary condition to asthma of extremely severe eczema, so I was

doubley miserable! Well, I had enough. I filed a letter of complaint

against Oxford with the New Jersey Department of Banking and

Insurance. Do I expect anything good to come of it. No. Oxford

already notified me that they will review my file in another 6 months

(3/09), so I'll be going through it again. But if they do, I will

institute a law suit. My doctors are supportive, which is great. I'm

not a litigious person, but I feel I'll be fighting for all of us!

Happy Thanksgiving.

Marie Ruffolo

[Guest guest]

Marie,

Before your reauthorization period, you may want to write the medical

director for meds at Oxford and call his/her attention to

this " pattern. " Include a copy of the typed doctor's notes that were

submitted this go-round with your letter. Emphasize the fact that

the asthma piece is life=threatening, and so on. If you have a

friend who's a lawyer, you might want to ask him/her for

suggestions. Anyway, see if doing something pro-active in advance of

the reauthorization period may help.

I got my meds today, thank goodness. I am thankful you have yours

too. And you're right, anytime ONE of us fights, we are fighting for

all of us.

Addy

> >

> > Hello, all,

> >

> > A little over a month ago, my Xolair script was due for

> > reauthorization. Medco, BCBS of NC pharmacy provider, denied it

as

> > being non-medically necessary b/c I didn't have a qualifying IgE

> > score (despite the fact that I, of course, do). So I had to

> initiate

> > the appeals process. A couple of weeks ago, I faxed a letter to

> > my " appeals analyst, " after I got a letter giving me her name and

> > contact info. I detailed the problem AGAIN, blah, blah. Shortly

> > thereafter I had a terrible allergic episode requiring pred and

> > antibiotics. I'm still on pred. Tuesday I faxed her (after

> phoning,

> > she was out of the office that day), explaining that I was on

pred

> > and my symptoms were increasing and my condition deteriorating.

I

> > faxed again the next day, called yesterday, called again this

> morning

> > and said, " please let me know something by the end of the day. "

> >

> > Well, she called at 4:30pm and said she had gotten the medical

> > director to approve me to get a month's worth of Xolair until

they

> > figure out what the heck they are doing. (my words, of course).

I

> > called Accredo, they promised to call BCBS Monday am and get my

> drugs

> > shipped in time to arrive before the holiday.

> >

> > So, my recommendation is to squeak often, politely, and let them

> know

> > EXACTLY HOW MISERABLE YOU ARE.

> >

> > Addy

> >

> Sounds all too familiar. On July 24, 2008, I was due to renew my

> Xolair. The Insurance Company, Oxford, denied it, of course. " Not

> medically ncessary. " I appealed and they replied, " Need doctor's

> notes, " (they wait until you need you medicine!). This was the

second

> time they had done that to me (it was about a month of interruption

> the first time). But, ths time, when they recived the doctor's

notes,

> they replied (after 2 weeks!), " Doctor's notes illegible, " I too

> begged and pleaded that my condition was deteriorating, but no one

> cared.The doctor's assistant typed the notes and I waited another 2

> weeks. All total: 2 months had passed without Xolair. I have a

> secondary condition to asthma of extremely severe eczema, so I was

> doubley miserable! Well, I had enough. I filed a letter of

complaint

> against Oxford with the New Jersey Department of Banking and

> Insurance. Do I expect anything good to come of it. No. Oxford

> already notified me that they will review my file in another 6

months

> (3/09), so I'll be going through it again. But if they do, I will

> institute a law suit. My doctors are supportive, which is great.

I'm

> not a litigious person, but I feel I'll be fighting for all of us!

>

> Happy Thanksgiving.

>

> Marie Ruffolo

>