[Previous Months][Date Index][Thread Index][Join - Register][Login]
[Message Prev][Message Next][Thread Prev][Thread Next]

Re: [IP] Bc/BS Hmo Nevada - H approval

> I have posted a few times on my trouble with getting H approved by
> Hmo Nevada.  Since January, when I transferred to this insurance. my
> doctor has told me that they have sent in the request, I call bc/bs
> Nevada and they say the H is approved and I go to the Rx and they
> say that the insurance does NOT have an approval.  

They are saying that H is not in the drug formulary which is true.

> The pharmacist
> has finally gotten an explanation, after 10 calls with no return
> calls from bc/bs.  EVERY refill needs a brand new pre approval
> authorization, which would be every month as they don't allow
> refills for over 1 month.  They have never informed me, the doctor's
> staff, or either of the pharmacists that this was required.  

Check the EXACT language of your contract. Chances are that is says 
non formulary drugs are OK with a different co-pay. They probably do 
not say that a specific approval is required. If this is the case, 
they get one polite phone call from you  to inform them of their 
ineptitude after which a complain to the insurance commissioner is in 
order along with copies of all correspondence to your local friendly 
medical news reporter and the offices of your state and federal 

> They
> also require new pre authorization for every visit to my glaucoma
> and retinpathy doctors, although when my eyes become cloudy I don't
> really want to wait for approval and have paid for these myself. 

Get your doc to agree (in writing) that this constitutes a time 
sensitive problem for which waiting could impair you vision. Do the 
visit under the provisions of ER visits. Be prepared for a fight as 
you will certainly start one with this approach. Again, send 
appropriate correspondence to EVERYONE.

> Do
> they think that I will suddenly become cured, or do they go to these
> lengths in the hope that I will give up, and not do what is
> necessary, or pay for them myself, which is what my doctor believes?
> I have been very lucky, as my doctor has supplied me with 12 vials
> of H, at no cost, in the last year (paying $458/month for insurance,
> I'm not going to pay for Rx's).  I have never heard of these kinds
> of problems with other insurance that I've had in the past and I
> know that each bc/bs has their own rules, but is this common? 

Well.... it apparently is common where you are. Keep us posted. It is 
possible to fight these organizations. It is easiest to do by beating 
them over the head with their own contract language. They usually 
always mess up in implementing policy and never ever have the "exact" 
required contract language to cover their respective butts, so if you 
have the energy and perserverance, you can beat them at their own 

email @ redacted
for HELP or to subscribe/unsubscribe, contact: HELP@insulin-pumpers.org
send a DONATION http://www.Insulin-Pumpers.org/donate.shtml