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Author Topic: I need some help dealing with denied prior authorizations from Blue Cross  (Read 1100 times)

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Offline newyorker4757

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  • Posts: 1
During the past 6 months I have been prescribed 2 medications, tricor (cholesterol medication) and testim (male hormone replacement).  Neither of these meds is on my prescription formulary, so I paid for them out of pocket.  When i informed my doctor's office about the problem, they contacted Caremark, the prescription supplier for Blue Cross, and faxed the prior authorization request, stating the first date the prescriptions were issued. 

In both cases Caremark has issued the prior authorization as of the date that they made the decision, ignoring the request for coverage as of the date of the first prescription.  When I phoned them to ask, they said that they could only back date the prior authorization 1 month, meaning that I'm now stuck with close to a thousand dollars of out-of-pocket prescription payments.  Anyone know how I can report them for unethical practices, or just get some satisfaction? 

I can't afford to pay over a thousand dollars a month for individual health coverage when the make unreasonable denials like this and I lose money...

Offline Cliff

  • Member
  • Posts: 2,645
I don't know if this is an employer-sponsored plan, but if it is, you can usually file a complaint with your benefits administrator.  They usually have an outside arbitrator who will hear such disputes and make a decision accordingly.  Check the details of your health coverage and contact your benefits administrator (you need not give them the specifics of your claim).

If that doesn't work, then your state should have a department that regulates the insurance industry.  You can file a claim with them.  I believe this is the department's website for the state of NY.

http://www.ins.state.ny.us/hpoffnos.htm

Offline Christine

  • Member
  • Posts: 1,069
Do you have a caseworker or social worker? I had problems getting Procrit filled a few months ago, and after getting nowhere with the insurance company myself, my social worker solved the problem in a few days. Wouldn't hurt to try.

Christine
Poz since '93. Currently on Procrit, Azithromax, Pentamidine, Valcyte, Levothyroxine, Zoloft, Epzicom, Prezista, Viread, Norvir, and GS-9137 study drug. As needed: Trazodone, Atavan, Diflucan, Zofran, Hydrocodone, Octreotide

5/30/07 t-cells 9; vl 275,000

Offline kentb

  • Member
  • Posts: 75
Newyorker, if I am reading this correctly you have an Individual Medical Policy.  If this is true then you can file an appeal with the carrier.  When you write the appeal put it in very simple terms, or use language you would normally use in general conversation.  But do provide facts, dates of Rx fills, proof of expenses, paid receipts.  The fact that you were covered at the time the loss occurred seems like you would be eligible for the benefit.  NY has a very aggressive Dept. of Insurance and I would file a copy of the appeal with them if you feel the necessity to step it up.

Kent

 


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