Help Me Get Insurance Approval!
Posted 19 October 2007 - 07:57 AM
Posted 19 October 2007 - 11:17 AM
Posted 19 October 2007 - 12:07 PM
Just type Cochrane library into google and click on the link that says Cochrane library or Cochrane collaboration. You will see a search box at the top right hand side- type in Iloprost and it will come up with the review which you can download or printout.
Posted 19 October 2007 - 03:15 PM
Dave in FL
Posted 20 October 2007 - 04:39 AM
Posted 20 October 2007 - 05:15 AM
I am so sorry you have to even spend energy on this. I believe Dave is right. (I really love this board and having so many experts here to help each other)
Please us posted.
Posted 30 October 2007 - 09:40 AM
Thank you too Gidget, for your lengthy response. I did sit in on the last panel, over the phone, they are in WA and I am in NY. I told them how I have already lost the tip of one finger and also that I cannot take most other meds because of my heart issues. They still said no. I will look into finding out if they ever covered anyone else. Any ideas on how to do this? And yes, my doctor has written many peer reviewed articles and is a major scleroderma expert. I LOVE him!!
Posted 01 November 2007 - 12:39 PM
Good luck! I have Blue Cross/Blue Shield in CT. The best way to find out if they have covered anyone else is to use your doctors. office to see who else has the same RX and the same insurance. Maybe your doctor can recall doing the same appeal process for someone else. Under HIPPA laws, you cannot get the patient's info but you can certainly argue the point with BCBS.
The next step is to go to your Human Resource Dept of your employer and talk to whomever handles benefits. Your benefits person probably does not even know that experimental is excluded. When talking to your benefits person, be sure to tell them how the other insurance covered the drug. Ask your benefits person to contact their rep at the insurance company and discuss getting this drug covered. Unfortunately, many benefits people are just interested in keeping the benefits cost down or the same to the employee and do not realize that the insurance companies are adding more and more exclusions to the policy -- such as "experimental" which is a problem for anybody with an autoimmune disease as everything is "experimental".
Also, if they cannot get BCBS to budge, then ask the company to directly cover the drug. It sounds like your company's plan is self funded and administered by BCBS. As such, your company can agree to cover the drug in which case BCBS will not care as it will run outside the administration of the plan.
As you are in NY, I assume that there is a health care advocate you can contact as well. Again the issue will be if your state's insurance laws apply to self funded plans such as BCBS. If so, then the BCBS cannot "hide" behind the experimental argument as your state laws will require them to cover the drug if it is deemed a "medical necessity". If this is the case, ask your state's attorney general office to write a letter on your behalf to both your company and BCBS advising them that they need to revisit your claim. At this point, it is of course helpful to be able to tell your attorney general's office if the drug has been covered in the past for other people.
In the meantime, keep up your appeals. Hopefully you will get lucky. I have been through the experimental hoop with BCBS with regards to a SCT and it is not fun. It is soo frustrating as they deny your request but do not offer any other treatment plan.
Also, in working with BCBS, they refused to cover my Nexium. I had to try all the other similar drugs and say they were not working (which they were not) before they finally covered the Nexium. This is certainly frustrating. I am assuming that there is no other drug available that BCBS will cover that you can try and then go back to say it didn't work -- similar to my Nexium battle. They also will not cover Viagra for the Raynaud's as they consider it a "sexual aid". Don't even try to get that covered as you will turn 100 before they will have a discussion with you. Again, it all boils down to how your company has determined what your benefits with BCBS will be in their agreement with BCBS. In my case, my company agreed that Viagra was a sexual aid -- and hence the non-coverage. My company could just have easily have amended the agreement with BCBS for Viagra to allow for coverage relating to Raynaud's.
Best of luck. Gidget.
Posted 05 November 2007 - 12:01 PM
I will pursue the company aspect of your information. The appeal turn down letter actually did say it is my particular policy that prevents this...maybe...
I know you can't get Viagra, but have you tried to get Revatio? It is definitely approved for PAH and maybe for Raynaud's too. Check on it!
Unfortunately, I can't take either due to my heart issues. As my doctors are fond of saying I'm a complicated case, but aren't all of we sclero's?? Oh well, at least we have each other!