BCBS of CA & Amevive

[Snowman]

I'm considering changing jobs. A big consideration is that my current insurance carrier (United Healthcare) covers Amevive at 100%. The new job offers only BCBS of CA. I've heard that all the Blue Shields make these decisions independently (BCBS of MA may approve and BCBS of CT may deny...).

Has anyone out there had an experience getting BCBS of CA to cover any FDA approved biologic? How about a known problem?

Thanks in advance for your help!!!

[chaimFL]

Call and ask directly....they may not give you an answer because you are not a participating member, but it's worth a try.

A good option to find out would be to get someone from your potential new job, who obviously is a participating member to call BCBS and ask as if inquiring for themselves.

[Allie]

Another option is to call them yourself... Explain that in ur current job you are being treated w/Amevive, and would you be able to cont. this treatment if you move jobs. They will not tell you specifically, but you should be able to get a comfort level of what they would say. The key is you are currently receiving this treatment. You are not asking them to allow you to get this new, but cont. on your current course of treatment. (That usually gets you better results than a newbie)

[makeitgoaway]

Originally posted by Snowman
I'm considering changing jobs. A big consideration is that my current insurance carrier (United Healthcare) covers Amevive at 100%. The new job offers only BCBS of CA. I've heard that all the Blue Shields make these decisions independently (BCBS of MA may approve and BCBS of CT may deny...).

Has anyone out there had an experience getting BCBS of CA to cover any FDA approved biologic? How about a known problem?

Thanks in advance for your help!!!

I had BCBS of MA when I started Enbrel. I know they all operate independently. Geared up for the insurance battle at the Derm.'s office. He gave me the Rx, said it will probably take a few weeks of the Pharm calling the insurance, insurance calling the Dr., Dr. calling the pharm, etc.

Well I dropped off the Rx at the pharm on my way home. 30 minutes later the pharm called to say that because it was Friday, they would not get my Enbrel until Monday or Tuesday. I said wait a minute. This stuff is very expensive! Don't order it until I have been approved by the insurance company. They said you are approved with a $20 co pay each month. I couldn't believe it. My co pay was $35 for a tube of Dovonex. Go figure.

Next came a job switch and new insurance with Aetna. I thought, again I was going to have a battle. The told me that as long as I use their mail order pharm service I would not even have a co pay. I guess I am one of the lucky ones as I have heard so many horror stories about people not getting it.

My suggestion would be to contact the NPF and see if their patient advocacy group would be willing to make the call for or with you. They may have a little more clout. Also since you are currently using it, and hopefully your Doc. might say that it is the only effective treatment that works for you, you might have a great chance.

Lot of luck!

[Snowman]

Thanks very much everyone. It is so weird to have to focus on insurance coverage rather than the the job on its own merits. I don't want the prospective employer to view me as having excess "baggage", so I'm trying to do my research without their involvement or knowledge. I'm not at all concerned about them knowing I have psoriasis, but I am concerned about them misinterpreting this as reluctance to accept the job on my part.

Maybe my best bet is to call BCBS of CA directly and explain my situation. Hopefully, I'll get someone helpful on the phone.

Thanks again for your willingness to help and to share your experiences with me!

[mlf44]

When your doc prescribes a med for you, call the insurance co to see if requires a prior auth on the medication, if it does then YOUR doctor must do this. Insurance companies know that drugs are very expensive and they like doctors need to know that it is being used in the corect way. Insurance companies can make independent decisions BUT they must follow guidelines established by the Department of Insurance and Medicare. Even though you might not be on medicare they set the standard for insurance companies to follow. If a drug is not approved by the FDA theres a pretty good chance they won't cover it because of the guidelines established by Medicare and the DOI. You can always appeal any decision, you have that right. The most important thing to remember is to read your policy, ask questions and ask your doctor or nurse or someone in your doctors office about the authorization process, thats what they get paid to do, and do it while at the docs office so you don't have to make a million phone calls. Your employer is the one purchasing the plan from the insurance so if they go buy what they can afford, you might also find yourself not covered for certain things too.
It's a tough spot to be in but we all read our home owners policies and our car insurance policies so we need to read our health policies too.
take care!
Mary Lou