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blue cross’s ideas of cost control

December 6, 2009

…are not the same as mine.

I’ve been watching the healthcare reform saga unfold in congress vaguely attentively (meaning mostly I read op-eds about it, and did skim through the text of portions of the house bill that passed), and have been excited to see the cost control measures that have been included. Yet, as much as I applaud parts of the bills getting tossed around right now, I’m a bit torn about what’s gotten through so far.

Like the Stupak amendment.  That’s pretty massively uncool.

Anyhow, national politics aside, every so often I get absolutely enraged with insurance companies, and extremely fired up about anything that would start to clean up their act getting through congress.  By “every so often,” what I really mean is “every time I have to deal with Blue Cross Blue Shield.”

First of all, they owe me thousands of dollars in psych coverage right now, of which, $315 has surfaced, after literally hours on the phone with these folks.  That amount was paid to a hemophilia clinic in Aurora, rather than anywhere remotely connected with me or my healthcare providers.  Since my coverage is out of state, the customer service folks are in the midwest, and tell me that BCBS of Colorado is the one with all the information.  BCBS of Colorado tells me that they can’t help me, since my plan is not with them.  Methinks the left hand denies all knowledge of what the right hand doeth.  I have no idea if they even really do have any idea what goes on in the void between my payment to my provider and these mysterious checks that somebody issues that “were definitely cashed in June 2009.”  Definitely cashed, but never received.  Hmmm.

Second of all, they have consistently denied coverage of effective treatments to my mother.  As in, after years of unpleasant treatments that would result in brief periods of health, when she finally started something that was probably equally unpleasant, but could be done at home and resulted in much more consistent good health, they declared that she “wasn’t ill enough to need it.”  No, she wasn’t…when she was using it.  When they forced her to stop because of the costs, she once again has become ill enough to need it.  I hate these assholes.

And now, they’ve decided that her most important daily medication is too expensive.  And my dad’s.  And mine.

Under the guise of “cost effective therapy,” they have decided with 24 hours of notice that they will no longer pay for our treatment, unless we can provide testimony from our doctors that all the cheap options will not be effective.  Which, of course, is a process that requires a paper form to be filled out and submitted, and then no doubt bounced around their paper shuffling department for a month before they deny it again.

They make it sound so reasonable in their announcement, even.

Step therapy programs are developed using Food and Drug Administration (FDA) guidelines, clinical evidence and research. A step therapy program is a “step” approach to providing drug coverage. It is designed to encourage the use of cost-effective prescription drugs when appropriate. This means that you may first need to try an alternative, typically a generic drug, before we will cover certain medications prescribed by your doctor.

“Step therapy,” my ass.  Do they not think that there’s perhaps a good reason that doctors prescribe the drugs they do?  And that doctors are always interested in using “cost-effective” drugs where possible, for the sake of us patients, to save us money on our prescription co-pays?  I have never once been prescribed a brand-name drug without my doctor discussing why this one is better than the generics, or even asking me if I’d prefer a generic anyway.

I’ve been going through their “step therapy target medications” document to see what it is they want me to be taking instead of my primary asthma medication, Singulair.  They suggest over-the-counter generic Claritin.  Claritin!  I was hospitalized for a week as a child, consistently need systemic corticosteroids whenever I get a chest cold, and they want me to take Claritin for my asthma.

Granted, that’s perhaps the worst example of what they suggest, but all in all, I’m a little disgusted by the whole new formulary.  They list twelve different medications as alternatives, and of the twelve, I have tried ten of them.  Not to mention the fact that I am currently on two of them in addition to the Singulair that they’re now refusing to pay for, and another antihistamine that isn’t on their list of suggestions.  Yeah, I totally don’t need this drug to manage my asthma.  I think my eyes might just roll so much they fall out of my head.  The next best leukotriene modifier I’ve been on is apparently so expensive that it’s not even on their formulary, meaning that I can’t even get a waiver to get it paid for.

So, well, I’ve been gearing up for another battle.  I have twelve doses before we hit situation critical.  Wish me luck.

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2 comments

  1. You know, I’m not sure what’s worse – having health insurance, or not having health insurance.


  2. […] and how they did the same to some of my family for their respective most important medications (you can read the post here). The changes to their formulary were pitched as a “cost control” measure – so, openly […]



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