2 ms·

Blue Shield is notorious for not paying out enough of premiums for care. If you're having issues though, figure out who your PBM. (Pharmacy Benefits Manager) is

Blue Shield is notorious for not paying out enough of premiums for care. If you're having issues though, figure out who your PBM. (Pharmacy Benefits Manager) is that Blue Shield is contracting the pharmacy adjudication out to. Basically, get in contact with them, try and get an override, or get them to explain why you are not covered. If it isn't in the formulary your employer opted into, you're hosed; but there is usually one way or another to get them to give in, they will just make you go through maximum hoops. Ask for their clinical people if you can't get any traction. They will likely be the ones with hand on the knob for whether a drug is "worthy of coverage" or not. Magic words: Override,coverage decision appeal, utilization management/formulary question. They will tell you to check a website. Look up your thing in their formulary, if not there, abort. If in there, but high-tier, prepare for the prior-auth gauntlet. I gave up on BCBS and have resigned to paying out of pocket, but you might get luckier than me. They will generally fight tooth and nail to be difficult, but just keep a cool head and keep escalating. It's been a while since my last butting of heads but I'm gearing up for round 2. Also remember: You can pay out of pocket, but you'll be at the whims of that pharmacy. They'll generally help you work through coupons.

jjav 5y ago
Thanks for the tips, it is very exhausting to fight these. > Also remember: You can pay out of pocket, but you'll be at the whims of that pharmacy. They'll generally help you work through coupons. I did ask, but it was nearly $1K/week so can't afford that.
- salawat 5y ago
  Ouch! You have now reached beyond my "letters/phone calls to Congress" threshold. Generally doesn't get an instant response, a d may take months, but surprisingly does occasionally get some traction. More out of spite than anything else. However, there is increasing regulatory attention being directed at the space, and even some states have insurance regulators you might be able to hit up. It's unfortunate, but there are some drugs that insurers are simply not willing to be on the hook for, and if you're the unlucky person suffering from a rare, expensive to treat condition; the only way around it is to make a lot of noise and waves, and be open to trying alternative regimens. No one should have to go through that though. Good luck.

jjav 5y ago

Thanks for the tips, it is very exhausting to fight these. > Also remember: You can pay out of pocket, but you'll be at the whims of that pharmacy. They'll generally help you work through coupons. I did ask, but it was nearly $1K/week so can't afford that.

salawat 5y ago
Ouch! You have now reached beyond my "letters/phone calls to Congress" threshold. Generally doesn't get an instant response, a d may take months, but surprisingly does occasionally get some traction. More out of spite than anything else. However, there is increasing regulatory attention being directed at the space, and even some states have insurance regulators you might be able to hit up. It's unfortunate, but there are some drugs that insurers are simply not willing to be on the hook for, and if you're the unlucky person suffering from a rare, expensive to treat condition; the only way around it is to make a lot of noise and waves, and be open to trying alternative regimens. No one should have to go through that though. Good luck.