This Is MS Multiple Sclerosis Community: Knowledge & Support

I've got a problem and I hope someone on here responds who has some knowledge of handling these types of situations. As some of you know, I just started Tysabri. So you have to enroll in the TOUCH prescribing program. They not only tell you about PML about a thousand times, but they also 'do your insuarance stuff'. This all happens before you get your first dose so you know what to expect and all that, so it's kind of like having a coordinator in a trial; one person handles your case and so on.

Well I get the call in mid-late October that my UHC is covering it all and all I will have to pay is my office visit specialist co-pay which is $50 dollars. Keep in mind this is not only the dispensing pharmacy, but also Biogen. So I say "cool" and proceed to get my infusion. Well about 2 1/2 weeks goes by and the CVS/Caremark pharm. that handles this calls me and says I owe them $1,300 dollars. Well after I picked myself up, I call and they give me this song and dance about it not being a "medical benefit", and it's and injectable and they only cover allergy injectibles. Now granted they are going to pay 70%, but they say I'm on the hook for the other 30%. Now the lions share (900) of that amount is just satisfying the rest of my deductible, but that leaves me thinking I'm paying $420 every month.

Now if my policy only covers it that way, then so be it. But I feel like I was misled initially and they need to cover this first one. If they prove to me that what they are telling me is true, then so be it. However, there's a back story. Some of you who know me also know my wife just got her RN. Well her insurance will kick in the day she steps across the threshold on her first day (in about 2 weeks once she get auth. to take her state board). Well had I known that I was going to be hit up for $1,300 dollars, I would have waited. We have already looked at the coverage, and it will only be slightly more than my Avonex was per month.

So I make a decision to purchase goods based on the information presented to me by not only the drug co., but also the dispensing pharmacy. Like I said, going forward, my coverage is as it states. But I feel like they should pay for this one. I have my ass covered six ways from Sunday. I talked to the guy who left me the message from CVS/Caremark, and he said when he looks up the coverage, he still sees fully covered; so does Biogen. So the gal at Biogen gives me the exact time and the name of the person who verified coverage at UHC. And to boot, they did it twice about two hours apart. It's a shame they have to do that, but it's good they do. So now I have the names from Biogen, and also the guy from CVS/Caremark all saying the same thing, and UHC saying another. If I was litigiuous (I know that's spelled wrong), I'd sue their ass off for emotional damages. You guys know how high strung I can get, and this has had my BP up. And to be truthful, I am incredibly distressed. I'm going to kill myself for saying this, but I think it may be helping. Now I say that pessimistically. I would say cautiously optimistic, but after the Tovaxin debacle, I just don't know if anything works very well after seven years. Lots of people at work have said in the last two weeks "are you feeling better?". That's all I'm going to expound. I already went down 'knee jerk to a couple of good days road' and don't plan on going back down it. Too big of a letdown.

So even if they prove that what they say is true, I think they are at least liable for the $1,300, and I'll abide by my coverage (even though I'm dumping them) going forward. But they armed me with information about the drug, and it's not like I can take it back like a Christmas sweater.

Does anyone agree based on what I just laid out? That's all there is; 100%.

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http://myhopefuljourneyintoactualmsreco ... ogspot.com

man you got them. if caremark has all this info and they verified with them and so did biogen then there paying for this one. thats all i would say..i will pay for the rest of the treatments but they need to pay for the first one. its not that the adj just goofed and stated that to you. she said it to two other companies..i would speak to a supervisor and explain how unprofession this is that they would call you and let you know that its paid for then state it wasn't..after you have the treatment. i would play the emotional card as well.

you are in the right on this. don't back down from them. also don't stress about it. or you can keep telling caremark and biogen to go after them for the money since they stated to them that it was paid for. thats what i would do..have the companies fight it out. good luck.

The last company where I worked had UHC. I remember I tried to get clarification if a procedure was covered (nothing to do with MS), and the people I got on the phone were incredibly clueless. Depending on which day I called, I got a different answer.

Finally, I got our HR department involved, who got their benefits coordinator to look into it. They got me some answers, but to be honest, the girl who handled insurance matters at the doctor's office was the one who knew what hoops to jump through.

Hi Loobie,
I'm sorry to hear about the problems with your insurance company. I've found that sometimes you need to get your doctor's office to deal directly with them as they'll try to run right over an individual patient. You might be interested in reading my experience with my old insurance company which denied a claim which was preapproved.

NHE

I discovered this problem when I started taking avonex seven years ago. My insurer and the pharmacy coordinator stated my avonex prescription would be covered under pharmacy and my cost would be reasonable and yet I received a bill from the pharmacy for the whole amount 2 months later. After much frustration and many phone calls I learned that my insurer covers "injectables" under major medical rather than pharmacy. The end result was that I had to pay 30% until my deductable was met.

Lew
Can you get your benefits person involved? Give that person all of the info and let him/her fight it out with UHC. Then you can take a step away so as to not stress yourself out. Remember that UHC contracted with your company, not you personally, so it is the company's responsibility to make sure they provide coverage as agreed upon. Whenever I have a problem with Aetna (my provider) I send it straight to the benefits person and let them deal with it. It is their job.
Good luck
Lori

Lori,

I have done that. My HR person contacted our actual agency (Brower Insurance), and I have a meeting set up for Friday to get him to take this over. I'm not kidding when I say I think I've spent 8 hours on the phone. I almost just took a day off, but I didn't have the confidence that dedicating an entire day to nothing but that would still get it resolved! My big thing now is how to "unstick" my next dose, which BTW I'm supposed to get tomorrow and they haven't shipped it out yet. This is just driving me insane. I finally get something that makes me feel different and now I may not be able to afford it.

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http://myhopefuljourneyintoactualmsreco ... ogspot.com

The one way they can cover themselves and Do cover themselves is this way: When your Dr., pharmacist etc..calls to verify your coverage, even if they say it's covered 100%, they always follow with their "disclaimer" that basically says....this COULD be wrong though and if it is, so sorry.
I used to get so mad about it.

Wondering if anyone has gotten anything from their Dr.'s about them not dealing with the health insurance companies anymore?

After finally finding the right Dr. and diagnosis, The practice has decided not to renew contracts with several of their health insurance providers.
Blue Cross is my provider, I know that United was mentioned as well as Humana and some others. It is a 3 page letter that is very interesting indeed and very indicative I think of what to expect on a bigger scale in the coming days for others.

Happy to scan it and post if anybody is interested.
The Dr. comes right out and dogs the insurance providers and asks that patients contact their government reps, as well as write letters to the insurance companies.

I kind of thought, "you go doc!", until I realized I would now be "out of network" with him which means quite a bit more out of pocket on top of my personal policy that is already $670 a month!! And that was before MS diagnosis! That huge increase was supposedly due to recurring kidney stones, obesity and high cholesterol.
I have a feeling their will be a day when I have to pay $1,000 a month just for my policy.

It's time for this country to make some big changes in healthcare.

You can go to www.change.org (obama's transitioin site), and vote or post comments regarding health care changes if you are so inclined. You can also sign up for a request to be a part of a regional/national ...shoot...word is leaving me....brain lesions..
well, a group of citizens that gather together to talk about these things and express their opinions. I'm sure the name will come to me as I press send so here goes....lol