Posted 5/11/2024 11:37 PM (GMT 0)
Old Hat,
Make sure you read your brochure/policy carefully. Get copies of the formulary.
My insurance has CVS/Caremark on the prescription side.
I get Remicade. I have Medicare. Since it's an infusion Medicare pays first and then BCBS picks up the rest. This year BCBS medical side denied my January and February infusions and sent a letter I needed pre approval thru the medical side. So the medical side finally approved Remicade but we are still wrangling over January and February infusions. (I had to drag in so many doctors and outside sources to get Remicade approved thru the medical side that it was a nightmare. Every doctor on my team had to verify that Remicade had to be administered as trying a bio similar might throw me into a flare that would be life threatening.)
During the medical pre approval process somehow the CVS/Caremark prescription medication side got involved. Even though infusions have been paid thru the medical side and the prescription side is not paying for it out of the pharmacy side, CVS is demanding that I obtain pre-approval thru their side also---and they then refused Remicade. They are demanding I use a bio similar because that's what is available on the prescription side. Name brand Remicade has to have a special authorization because it's so expensive.
Long story short...BCBS medical is telling CVS prescription side to butt out and yet....they won't. They are demanding I use a bio similar. And now I've reached out to the insurance regulators and my congressmen on both sides to try to get help. BCBS medical has said I'm ok. I can get me Remicade infusions and they will be covered.
I don't know if it's just this one CVS prescription medicine agent that will not stop or the whole CVS prescription department that's messed up. I just know that when I call in I usually get this one female prescription agent --like my account has been flagged, and is assigned to that agent every time I call in with prescription questions.
I've had to wrangle with them for VTAMA cream. They were trying to make me take something else and we had to go thru the hoops for pre-approval on that too.
Gotta admit--its been a difficult year. That young lady takes it personal when she has to send me out a pre-approval letter. I swear it makes her cry. The company must love her cause she takes her job seriously and tries to save them as much money as she can.
But on the other side of the debate--Ive got friends that are not experiencing the same hassles. (They have the same insurance) So maybe the insurance companies decided to audit A thru C this year and give those people a hard time...lol ...
Read your medical brochure and your formulary and your prescription brochure carefully. Expect them to follow it to a T and be prepared to advocate for yourself just in case.
Clo