Welcome, Guest. Please login or register.
January 17, 2018, 09:16:26 PM

Login with username, password and session length

  • Total Posts: 725235
  • Total Topics: 59113
  • Online Today: 312
  • Online Ever: 1421
  • (August 13, 2016, 05:18:44 AM)
Users Online
Users: 3
Guests: 271
Total: 274


Welcome to the POZ Community Forums, a round-the-clock discussion area for people with HIV/AIDS, their friends/family/caregivers, and others concerned about HIV/AIDS.  Click on the links below to browse our various forums; scroll down for a glance at the most recent posts; or join in the conversation yourself by registering on the left side of this page.

Privacy Warning:  Please realize that these forums are open to all, and are fully searchable via Google and other search engines. If you are HIV positive and disclose this in our forums, then it is almost the same thing as telling the whole world (or at least the World Wide Web). If this concerns you, then do not use a username or avatar that are self-identifying in any way. We do not allow the deletion of anything you post in these forums, so think before you post.

  • The information shared in these forums, by moderators and members, is designed to complement, not replace, the relationship between an individual and his/her own physician.

  • All members of these forums are, by default, not considered to be licensed medical providers. If otherwise, users must clearly define themselves as such.

  • Forums members must behave at all times with respect and honesty. Posting guidelines, including time-out and banning policies, have been established by the moderators of these forums. Click here for “Am I Infected?” posting guidelines. Click here for posting guidelines pertaining to all other POZ community forums.

  • We ask all forums members to provide references for health/medical/scientific information they provide, when it is not a personal experience being discussed. Please provide hyperlinks with full URLs or full citations of published works not available via the Internet. Additionally, all forums members must post information which are true and correct to their knowledge.

  • Product advertisement—including links; banners; editorial content; and clinical trial, study or survey participation—is strictly prohibited by forums members unless permission has been secured from POZ.

To change forums navigation language settings, click here (members only), Register now

Para cambiar sus preferencias de los foros en español, haz clic aquí (sólo miembros), Regístrate ahora

Finished Reading This? You can collapse this or any other box on this page by clicking the symbol in each box.

Author Topic: I need some help dealing with denied prior authorizations from Blue Cross  (Read 2039 times)

0 Members and 1 Guest are viewing this topic.

Offline newyorker4757

  • New Member
  • 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.


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.

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.



Terms of Membership for these forums

© 2017 Smart + Strong. All Rights Reserved.   terms of use and your privacy
Smart + Strong® is a registered trademark of CDM Publishing, LLC.