Blue Cross/Blue Shield suddenly kicked me off my prescription plan

Sorry this is a long post. I hope someone might have some ideas for recourse as I don’t have weeks to sit around waiting for BCBS to maybe fix their issues. So to start this and express why this is such a bad time for this to happen, the last 10 days have been challenging. I’ve had to do more breathing treatments than at a point I can remember for a long time. 5 nebs per day (more than I should be) plus additional rescue inhalers in between. It’s been a struggle (especially at night).

Yesterday I went to the pharmacy to pick up my nebulizer treatments as I’d used the last one that afternoon. I also needed to pick up a new Advair script to hopefully help settle my lungs. When the tech brought them out, instead of getting my low copay amount, she said I owed $1,120. I laughed and said she forgot to use my insurance, she went back and said, “I’m sorry, but on June 20 Blue Cross kicked you off their prescription plan”. Aghast I said it has to be a mistake. That’s crazy. It’s impossible! I asked if there was anything she could do. She said no but you can pay for them yourself. The pharmacist saw what was going on and came over to tell me this has been happening a lot with BCBS and they refuse or are too incompetent to fix the issue properly as it keeps hitting big swaths of plans. So I went home with no medications. Ended up with coughing spasms til 6:00 am when exhaustion finally pushed me to sleep.

Today I called BCBS and they said, “there’s a systems issue and someone will try to attend to it”. I asked for an ETA and they refused to give one. When we asked what I’m supposed to do, she said pay for it all up front and send in receipts for reimbursement.

I went back to Wal-Greens today and my favorite pharmacist was there. He’s amazing and has been taking care of me for 20 years now. What he told me was shocking. This isn’t something new. BCBS has been doing this to people/companies all year. He’s part of a network of pharmacists from across Michigan/U.S. and said this has been a continuing and repeated nightmare. He believes people are getting hurt being forced to go without their medications because they don’t have the money to pay for meds up front while BCBS sorts out their problems. Diabetics suddenly forced to go without their insulin, cardiac patients suddenly without their heart medicine. Pulmonary patients suddenly having to go without breathing meds. Thankfully because he knows me so well, he gave me an advance on my neb treatments to get by for a bit. When I told him what the BCBS rep told me, his words were:

“UNDER NO CIRCUMSTANCES SHOULD YOU PAY FOR YOUR PRESCRIPTIONS UP FRONT. There is a good chance you will NEVER see that money again. He said BCBS has been denying reimbursement when people have been inadvertently kicked off their policies, and often when they do pay, it takes 6 weeks to 6 MONTHS to get your reimbursement.”

I’m floored. I’ve never had a single problem with BCBS before, they’ve been fantastic. I had no idea part of their company was such a mess. Here’s a not fun part that has me concerned. I have to get my Trikafta next week from a special order pharmacy. It’s the most important medication I have for my lungs. It costs $22,000. Even if I felt confident I’d have no problem getting reimbursed, I don’t have that kind of money in the bank. And I can’t help but think… “I” have the capacity to try and fight to fix this before something bad happens, but what about the elderly who are on their own who don’t have a support base or don’t have resources. Or the patient who’s critically sick in bed, and doesn’t have the strength or mind to try and work through red tape? It makes me incredibly upset knowing how awful this could be for some people who just need this system to work. So how does a peon like me get through to someone at BCBS who can actually make a difference and fix this faster? Obviously the first point of contact has no power, and half the time hates their job.

For my final note of something I find odd. I can’t find a single comment/article on this problem anywhere on the Internet. My pharmacist(s) have made no bones about what a damaging, widespread, nightmare this is and they can’t believe a regulatory agency hasn’t become involved. So why isn’t anyone else complaining about this on the Internet? I posted some info on my local reddit sub as I thought it was an issue in just my city and got responses verifying what the pharmacists had stated.

Had something similar happen here a couple of months back with Premera (also BC). Same as your story, the cVS said it had been happening a lot. It seemed to straighten itself out in …don’t recall the exact timeline but want to say it was a week or two. A paid for a few prescriptions at the time, but they weren’t expensive or anything

Unfortunately I don’t have that kind of time.

Was my post too long and annoying?

No, not at all. I realize it isn’t helpful (that timeline), just confirming that this really is happening elsewhere. Do you get your insurance through an exchange? Any chance the people there could help?

Through my wife’s employer (large government entity). Trying to get human resources to actually do something. She talked to them yesterday and they did nothing. I wrote a letter for her to take to them expressing the urgency involved and how countless other people within the employee ranks may also be affected. Will see if that puts a fire under them tomorrow.

Honestly, these days, the quickest way to get attention is often on social media. Do you use Twitter? You could try tagging BCBS and the pharmacy there.

Find your local tv news “troubleshooter” and tag them too

I did, then I deleted it. I got scared they’d start getting aggressive in claims denials.

See if your wife’s employer has something like a benefits ombudsperson. Where I work, we have people in HR who can act as intermediaries with insurers, etc., and I’ve used them to fix problems in the past. Not with BCBS mind you, and not with this exact issue, but often you can get better angles of attack and reach more useful people if you have someone with more clout doing the reaching.

Hey Jeff, here is some info that may be useful to you. I’ve represented insurance companies in workers’ comp cases for many years and I’m familiar with the way they do things. This is not legal advice as I know nothing about law in your state (MI?) but I do have experience with the way insurance bureaucracies functions, so hopefully this info will help.

You described going through BCBS without any success, and them telling you there was systematic stuff going on. So here’s the deal: the human beings you talked to probably don’t have the power to actually help you. Insurance companies routinely place limits on what their humans can do, using computer programs and so forth.

Let me give you an example: for many years I struggled with the issue of getting my insurance company clients to pay amounts ordered by courts. In order to spit out a check, the insurance company computers require certain things like an address and tax ID # that match the computer system records. I had many cases where the insurance company computers were out of date and the current correct info I provided (which was like RIGHT ON the court orders - that’s how I wrote them in an effort to make them idiot proof) didn’t match the incorrect and outdated insurance company info. And no matter how much I screamed and warned the insurance they were going to piss off the Judge and eat penalties and interest and maybe sanctions, they’d be like “I literally CANNOT issue that check. I put in the info, it doesn’t match, the computer simply refuses to spit out the check. Bzzzt.” So inevitably I would have to scramble to update their info for them, or in a few rare cases, escalate things up to the management level where there were humans who COULD just write a check or make the computer do so.

And that latter bit is where you need to focus. These insurance companies do not actually want to kill you by depriving you of needed medication, not out of the goodness of their hearts, but due to fear of the business badwill, bad publicity and lawsuits. Jpinard dying due to insurance company fuckery would be truly terrible for Jpinard but also bad for the business of BCBS and they hate things that are bad for business. (Sorry for the snarky framing but it is what it is.) What you need to do is escalate your situation to the level of a human with the executive power and mental judgement to do something to help you. The lower level folks might be uncaring a-holes or nice folks who want to help; doesn’t matter. They almost certainly lack the power to help you. This lock on authorizations you describe is almost certainly a high level policy thing that the schlubs in claims and administration can’t do anything about. You need management.

So, here is what I suggest: first look at all your info to find out if BCBS has an ombudsperson, some sort of process for “high risk” patients, or other safety valve type process to get your situation in front of someone who has the actual power to help you. If they have that, go that route emphasizing that you are a high risk patient with a life threatening condition and that medication interruption could kill you and hurt their business and they really don’t want that (you can say the latter part as earnestly or as snarkily as you feel appropriate.) If they don’t have those kinds of ombuds/safety valve pipelines, then you need to go through the normal channels, but again emphasizing what I said: you are a special case, this is serious, a bad outcome for you is also a bad outcome for them (don’t threaten lawsuits; they’ll just punt you to legal - focus on the serious reality of your situation). Basically, you need to talk to someone who has the actual authority to do something. Keep in mind, it might not be just a simple “OK your stuff is authorized” - they might force you into some weird stopgap BS that gives you just enough meds to survive, but hey it’s better than dying.

So: work your way up the chain to a person with real authority, emphasizing the seriousness of your situation but avoid threatening lawsuits and be willing to be flexible. The reality is, corporations are not people. They have no desire to kill you but they will blindly do so as their gears grind if you get caught in the gears. If you can point out the essential fuckedness of your situation to a human who has the right level of power, they will highly likely do something to help, not because of warm fuzzy human generosity but b/c in addition to you dying being terrible for you, it would be bad for their business. (I’m fully aware that’s a genuinely fucked up way to frame this issue, but hey, many years dealing with this shit; I know what I’m talking about.)

So, running into a wall at a low level? That’s just par for the course. You need to escalate to a level where human judgement can help you, without triggering “lawsuit defense” mode and with a willingness to be flexible.

That’s my 2 cents.

(None of the above is legal advice in any way shape or form - I know nothing about the law of your state - if you want legal advice, talk to a lawyer licensed in your state. But from a standpoint of how to deal with bureaucracy, that’s my input.)

As I think about this, I realize that in addition to doing everything you can about your administrative options as I outlined you should almost certainly talk to a lawyer licensed in your state as well. And definitely don’t agree to anything legally binding without talking to a lawyer.

Damn, that was super helpful in general, thanks! And it shows that we should never attribute to malice or conspiracy that which can best be explained by sheer incompetence.

Does your wife belong to the union at her large government employer? There should be someone at the union office that handles insurance issues.

I’m no expert in business or high finance, but isn’t it a big red flag when a company can’t pay its bills (or reimbursements in this/these case/cases)? Doesn’t that usually mean they’re struggling with cashflow problems?

I didn’t think I’d written BCBS was trying to hurt people, but it may have come off that way as I may have channeled the pharmacists anger dealing with this same issue over and over. I found a Grievance and Appeals Process when looking up ombudsman at BCBS, but the only way to do this is via old fashioned letter. Calling again to see if they can get me to a different department with more power to do something.

Yes she does. Hadn’t thought of that and will have her contact them.

It looks like (once you file with BCBS) you can also get the state Department of Insurance and Financial Services involved. You might also want to look at state level political representation (e.g. your state senator or state rep) to light a fire under BCBS and/or the Dept. of Insurance and Financial Services.

The union suggestion was also good – I saw online that UAW in particular has an ombudsman to deal with BCBS, so your wife’s union might, too.

Like @Aleck, I was going to suggest contacting your local rep, either in state government or the House–my rep has a form to fill out for miscellaneous help requests. I think they’re really just fishing for things they can make hay out of for politics, but “insurance giant intransigently denies lifesaving medicine” might be one. Also, maybe your state AG? Though here in MA we’re a smaller state so our national political figures are a bit closer to ground level, so to speak.

Hey @jpinard, talked to a close contact who works in the insurance industry and she had specific advice including who to ask for at BCBS (case manager) and the proper escalation route at the state level. See my PM. Hope this helps!

That’s perfect. Thanks!

Holy cow. This is way worse than I thought.

Blue Cross kicked off over a thousand city employees from their prescription coverage. Lord knows why they can’t just put them all back. Now the city is scrambling to try and offer emergency coverage options to get people through the weekend while BCBS tries to figure out how to fix their systems.

We spent all day on the phone with insurance/benefits, multiple departments at BCBS. The first call today the rep was rea snippy. “I don’t see what the big deal is. You can still get your prescription. Just send a receipt.” I’m like, “Do you have a spare $22,000 sitting in the bank?!” After it got escalated, the next department was really great, who then got in an argument with a 3rd department who refused to believe we were really kicked off the prescription plan.

So now, still don’t have 2 of my 3 breathing meds, not sure when I’ll get them. There’s nothing else I can do since all associated parties know what’s going on, who’s at fault, and we wait for them to fix it. According to another individual who’s company went through this exact same ordeal, it will take BCBS 2 weeks to fix.

How serious is this? Is missing those 2 meds one of those “this sucks but won’t kill me” kind of things or is missing those meds “this is a serious health risk” kind of thing? If it’s a serious health risk, then try seeing if you can escalate higher up the chain on the department that was working with you.

The other alternative if you are facing a serious health risk would be for your doctor to send to the hospital for medication treatment but I don’t know how that works in your circumstance, and you are probably already on top on that option if necessary.

Stay safe, Jeff, and don’t let the bastards grind you down. Specifically, this “we wait for them to fix it” thing; I don’t agree that’s the hard reality. They SAY that’s what has to happen but somewhere up the ladder there is a person who can say “FIX THIS” or at least “give Jeff a temporary fix! NOW!”. If you need to go up there, then do it. Hopefully that won’t be necessary.