Insurance woes

[Guest guest]

Well I just went through another odyssey with insurance but it turned

out okay and I thought I would give a few tips. After two and 1/2

years on xolair, Blue Cross of Calif. decided to do a " retrospective

review " and denied further benefits and revoked benefits for

treatment already given. Unbelievable. I appealed. I made sure my

allergists records were forwarded for an appeal, and also received

letters from other specialists (Nose, EAR) where xolair has also

helped who noted that it would be unethical and malpractice to deny

coverage. I submitted them as my appeal in addition to my

physician's appeal. Blue Cross reversed.

Then my employer decided to change plans. I was now covered by Blue

Shield of Calif. With Blue Cross, Caremark, the national pharmacy

distributing xolair for these plans, prepares with the physician a

submittal for approval but does the submittal. However, Blue Shield

wants it straight from the physician. Neither my physician staff or

lower levels of Caremark staff realized this and a month went by

while my xolair supply dwindled. When I called Caremark to find out

what was going on. staff elevated the problem and it finally got to a

wonderful Vice President of the company who understood exactly,

mobilized Caremark staff and worked closely with my physician's

fairly inexperienced (in insurance coverage only) staff to get a

claim properly submitted by them and processed by Blue Shield. They

also offered to provide medicine while things were pending.

Wonderful, and cudos to them. Blue Shield responded within a week.

I am again covered.

So the tips are:

Understand the particular procedures of the insurance plan and help

your phsyician's staff to understand it. Work with the pharmacy

companies and get the right people on it. Help your physician's

staff to understand they should prepare a submittal like it was their

last will and testament. If the insurance company acts bizarrely,

appeal with the best documentation and expert statements that you can

get, and if things get bogged down, find out way and solve the

problem. Good luck out there.