On August 1, 2011, I switched to BlueCross and BlueShied (BCBS) after having been on another program for many years. After having made this switch, on August 11, 2011, I was told that one of my medications was not covered. After about 16 phone calls to my doctor, my pharmacist, and BCBS, and after having received 8 difference stories each time I called BCBS, I finally learned that what was required before my Rx were covered was that I needed to go through "step therapy." This means that I (and by I, I mean my physician) needed to show that I had tried x amount of cheaper medication prior to being on these particular medication and why I was on these before they would agree to pay for them. Sounds simple enough. So BCBS faxed over the form to my doctor Now here is where I should note that medication is birth control and time sensitive. I was told by the BCBS rep. that if my physician marked "urgent" on the form that it would be processed within 3-5 days. I contacted my physicians and relayed this message to them because the form which is faxed to them or that they can recover on their own from the internet, has no instructions for how to expedite the process. I should also note, that I am away at school at the moment and am not living at home. All of my addresses have been changed accordingly with BCBS only to reflect this information that my mailing and shipping address are X. However, ignoring this information, BCBS, after approving Med 1, on August 22, 2011, mailed a letter to the primary insurance holder's address and not my mailing address to advise me of the status of my medication. Moreover, the Med 1 did not arrive until August 30, 2011.
On August 24, 2011, I woke up with a cold. The cure for the common cold is fluids and rest; little did I know that I would not be resting for a very long time. On August 25, 2011, I went to fill another Rx ("Med 2")
which is a sleep aid. Due to the controlled nature of the substance, it can only be filled every 28 days, so with a thirty-count daily script, one can only fill it 2 days before they need it. The pharmacist told me that BCBS would not authorize my Rx. Shocked that this was happening again, I contacted BCBS and I was told that I needed to go through this Step Therapy process again. The BCBS agent stated that he could contact my physicians office and would notify them that he needed to mark urgent on the form etc. I also called my physician and left a message for them to expect this call from BCBS.
On August 29, 2011, I went to the my primary care physician because, since I had not slept all weekend, I now had an infection in my chest and was prescribed antibiotics. I took that Rx to Publix where I could get it filled for free sans BCBS. Over the next few days I called BCBS at least twice every day. Once I got through after punching numbers that was not my member numbers, but no one ever called me back with regards to my messages. I received conflicting information from when I called verses when my physician called. Additionally, the BCBS agent, never called my physician that week with regard to the form he was supposed to fill out. My Physician was faxed incorrect forms and then was told that I was not a member of BCBS.
Finally, on September 13, 2011, after having called BCBS every day to find out the status of the medication, the primary card holder received a letter at her address saying that Med 2 has been denied. That despite the fact that the form was marked urgent, and that I said I had previously tried x prescriptions, the Prime Theraputic Clinical physicians, (the division reviewing the forms for BCBS) decided that I should not receive coverage and that it was not urgent enough to call me or e-mail or mail their decision to the address provided for contact directly with me. I was livid. They based their decision that because I had not tried the medication within the last 365 days, that I should not receive coverage.
After a thirteen page letter detailed with dates and grievances faxed to the appeals department and the head of BCBS in Chicago, IL, the day that letter was received, I was granted coverage. Little did I know that this was a process that I would have to go through EVERY YEAR. So here I sit, on December 3, 2012, again without coverage for Med 2. I did not have the problem this year with Med 1 because, since that date, they have come out with a generic equivalent. However, for Med 2, none exists. If one did, I would gladly take it; but the only suggestions that BCBS has on their form are generics for other medications that are not the formulary for what I am currently taking. I have openly admitted to BCBS that I have not taken one of the X medications listed within the last 365 days but I have taken them and they do not work. If you do not wear a size 6 shoe, should I need to try one on every year to make sure it still doesn't fit? If I know that I am allergic to tylenol or asprin, should I have to try them every year to make sure that I am still allergic?
The scenario for this year is much the same, except this year, BCBS was even more outrageous in that they decided to completely ignore the fact that my physician marked urgent on the form. Their actions are completely arbitrary and their clinical physicians think that they know better than my treating doctor. Unfortunately, at this point, my physician just doesn't want to deal with it anymore. BCBS says that my physician can set up a peer-to-peer conference so explain my case, however, my physician does not get paid for that, so why should he? All I know is that they are ripping me and my physician off in the hopes that we will go away, but I refuse to go away quietly.