BCBS Still Limiting, Declined Response

Part II, continued
Blue Cross Blue Shield of Florida Neither Resolved This Case NOR Issued a Statement
   Continued from Blue Cross Limits Access To Meds 

More of this Feature • Sequence of Events • YOU Can Make a Difference        On Our Forum "...I went for eight months fighting with the insurance co. (BCBS) to get it. I got one Rx at the pharmacy and did mail in. The Rx was for the 3 months worth that I was told I had to mail in, but they kept refusing it saying I was over the max allowed. I spent many trips to the ER, which they paid in full and had to go 3 months with out meds at one time before they would fill the Rx." Join the discussion         Related Resources • Blue Cross Limits Access To Meds • Is Your Insurance Company Limiting Your Triptans? • Triptans: Overview and Profiles        Elsewhere on the Web • MAGNUM: Drug Utilization Reviews • MAGNUM: Limits Burden Patients • MAGNUM: HMOs Limiting Use of Migraine Drugs

 

Analysis:
It surprises and disturbs me that neither the promised phone call from a BCBS staff pharmacist nor any official statement from them materialized. Their lack of response leaves me to try to draw possible conclusions only from my limited conversations with Mr. Luke and their lack of response. Some possible conclusions include:

• BCBS offered two totally different explanations, which I was able to show to be unfounded:
  • limitations due to "FDA regulations" — although there are no such regulations
  • BCBS's incorrect information that triptans are thought to be addictive — triptans are not addictive.
• After those, Mr. Luke quoted a clause allegedly in Miss Brown's policy. When told that neither Miss Brown nor I could find it, and asked to provide me with a copy or tell us on what page of the policy the clause is located, Mr. Luke said he'd need to check into it and get back to me. He never was able to provide that requested information. Had it simply been a case of information on this alleged clause simply not been provided, I would concluded that it did not exist in Miss Brown's policy. However, since I have a copy of Miss Brown's policy, I am left wondering why BCBS attempted to tell me it is.
• Since BCBS has not shown a valid reason for their actions, they have failed to honor what Miss Brown's policy does say about prescription drug coverage:
  • "the lesser of a 31-day or 100 unit dose supply per prescription."
• In the absence of a substantiated reason for limiting access to medications, I am left to consider the possibility that BCBS may be falsely limiting their coverage for purely financial reasons, to limit cost. If so, this is very short-sighted. Covering a patient's triptan prescription as written by their attending physician is less expensive than the possible alternative of their having to cover emergency room visits when the patient is out of triptans or covering the costs of possible complications of an untreated Migraine episode.
• BCBS may have been unwilling to comment on the record because they have no valid reasons for these limitations.

Summary:

When asked for her comments on the current status of her situation, Miss Brown replied:

"At the very least, BCBS' silence on the matter shows a real lack of concern for their subscribers. I have now become someone that BCBS probably considers a burden because I have Migraines. I have been paying for a service which BCBS now refuses to provide. I cannot even get an honest answer as to why I can't get the Maxalt^® I need. I was brought up to believe in the necessity of health insurance. How safe should I feel now, with health insurance, that I will be taken care of when something comes up? Denying me what I have been paying for and lying about it is not acceptable. It would seem to me that there are some standards they would have to abide by and they are not. I will get to the bottom of it. They cannot respond because they have nothing to say. In similar circumstances there is a word for that."

When updated on this case, Michael John Coleman, Founder and Executive Director of MAGNUM, offered these comments:

"MAGNUM has been concerned about Medical access on various levels for over a decade whether it was a fight for the right of pain suffers to have access to the emergency room for so-called non-life-threatening illnesses or the aforementioned false limits of properly prescribed medications. One of the issues at heart is illustrated by Miss Brown's case which Dr. Robert and our organization have take interest in as it is a good illustration of one of the many current medical access issues. This is indeed a medical access problem.

"We must understand that MAGNUM has worked very hard to get reluctant migraine patients to appropriate doctors such as those in the American Headache Society who are trained to under stand Migraine disease and headache disorders with the most current and proficient understanding of these disorders. It is appalling to think that a managed care provider, whether a bureaucrat or a doctor sitting on a panel, would attempt to countermand an attending physician's written prescription. After decades of Migraineurs getting poor or inappropriate care for their Migraines, it is sad to see that in this more enlightened century, when Migraines are truly understood as a neurological disorder¹, that patients now have new roadblocks to deal with. But I can tell you as a public health advocate the climate for this kind of poor service that we are being forced to deal with more and more from our providers will not and should not be tolerated. To that fact, I was deeply grateful last week when President Bush noted in his State of the Union Address that:

'Instead of bureaucrats and trial lawyers and HMO's, we must put doctors and nurses and patients back in charge of American Medicine.'

"To those of you in this country struggling to receive the care you paid for, go forward armed with the words of our President and know that you truly deserve the best medical care, care that you have already paid for, and that decisions about your care, your treatment, and the medications you take are solely between you and your attending physician."

¹a position supported by the American Academy of Neurology, the American Medical Association, and other experts in the field
 

I am surprised by this situation having found Chris Luke of BCBS to have been professional, and accommodating, but his superiors have not been able to respond to the simple questions put forth through Mr. Luke. As BCBS is such a major provider, I  find this unsettling, unacceptable, bordering on irresponsible. I am going to continue to pursue this issue of false drug limits. My hope is that BCBS is not intentionally acting in bad faith and that we will soon see some of these issues resolved.

It should be noted that BCBS of Florida is not the only BCBS plan against whom I have received formal complaints. Further, BCBS is not the only insurance company/managed care provider against whom these complaints continue to mount. Here at About, with our partners at MAGNUM, we have compiled over 689 active complaints and will continue to pursue resolution to this problem of medications limitations.

In these cases, it is possible for some patients themselves to bear the expense of paying for the remainder of these expensive triptans they need. However, they are already paying costly insurance premiums, often with no advance notice of any limitations, limitations that I may add are becoming more and more apparent and questionable. Also, for many patients, the financial resources to pay for medications themselves are simply not available. Therefore this is placing a severe additional burden on policy holders.

Although the particular case we've been discussing involves a Migraineur, it's vital to realize that patients with many conditions and diseases are encountering such problems. In discussing this issue with Susan Denny, MAGNUM's Information Services Director, it was distressing to hear how seriously her health is being jeopardized by problems with obtaining mail order medications from her provider. Susan is a Migraineur who also has other very serious illnesses including severe type 1 diabetes and asthma. Susan's diabetes is so severe that she must wear an insulin pump at all times and test her blood glucose many times each day. If she is not testing to adjust her insulin dosage or does not have her insulin, a literally life-threatening situation exists, yet the pharmacist working for her carrier has reduced the amounts of both insulin and blood glucose testing supplies prescribed by her attending physician.

What Can Be Done:
Each of us can make a difference in this unacceptable situation. As MAGNUM advocates often point out to me, our legislators, our state officials, our government officials are there for US, and the only way these public servants understand where the problems lie is if we collectively do our part to make them aware of the problems that limit us from access to the care we truly deserve.

For information on what you can do, please click HERE.

             

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