insurance

[forkboy]

Hi,
Newly diagnosed hep c 2b. Doctor prescriped omeprazole, ribavirin and pegasys. Have BCBS insurance hmo plan.
The first two cost me a copay 15.00 ea but they will not cover the pegasys. Anyone else had this problem?

[Bill1954]

Congratulations getting that taken care of, and good luck with your upcoming treatment. Welcome to the discussion group, by the way—

--Bill

[forkboy]

Thanks for all the great advice about the insurance issue it gave me alot of hope that it would get resoved. Once I contacted the right person with bcbs she got the problem solved for me. She blames it on the doctor office, but the doctors office blames bcbs. All I needed was prior authorization form the doctor and for bcbs to forward it to the right office for coverage.

[R Glass]

My wife works for a Pharmacy. I read this to her and she said insurance companies have to give an explanation (even if it is by code) of why they refuse to cover any medication. You need to first find out what the excuse is. You can do this by contacting the pharmacy that will be supplying your Meds.
  A lot of people have BCBS and have no problem with them. I also have BCBS and have to watch them because they quite often try pull something slick.
Once they refused to pay for Lab Work because they claimed my Dr.’s office did not send the proper documentation. My Dr’s office said they faxed it them 3 times BCBS denied ever receiving it.
When I called them back, I didn’t tell them I was calling from my Dr’s office (my Cell Phone) and had her on speakerphone. My Dr’s office stepped in, told her who she was, she pulled the copy from my file and she faxed just prior to the call. She also told her we would stay on the line until she has it in her hand. In a few minutes she came back to tell us she had it and thank you (no apologies).
My Dr’s office told me this is common with BCBS and they are hoping we just give up and pay it. They know ribavirin and pegasys go together and ribavirin is basicly usless with out it. Even if it was human era they should have caught it.
“To Err is Human”, isn’t it strange how Human Era never seems to be in our favor?

[Trinity4]

If they approved the ribavirin there would be no reason to deny Pegasys.  Sounds very much like someone is not interpreting your diagnosis and RX correctly.  I also have BCBS and they are very good in reconciling things once they realize it should not have been denied.

Trinity

[Bill1954]

Yes, this should work out okay. The manufacturers manage patient assistance programs for uninsured and underinsured. You might need a letter of denial from BCBS to send on to the program, but give them a call anyway:

Pegassist (Roche Pegasys system): 1-877-734-2797

Commitment to Care (Schering- Plough PEG-Intron system): 1-800-521-7157

They covered 100% of my last two year treatment costs.

Good luck and let us know how it goes—

Bill

[medicmommy]

Talk to the billing Dept at your Drs office. They may have coded the diagnosis wrong and thus, the peg doesn't fit the "medical necessity" for the insurance company to pay for it. If that doesn't work, talk to you Dr AND call BCBS. This sounds like an error in paperwork somewhere, and perhaps an agent can tell you exactly why it isn't covered. If their policy has changed, try contacting Roche (the manufacturer) to see if they can help.
It may be something stupid like a rule that a hepatologist can only order Peg because a GP isn't a specialist. I have BCBS as my insurance and have found that, they are willing to help when you plea you case in a calm rational manner...(I tried screaming and irrational..-it didn't work for me...:) Good luck! ~MM