Insurance company gatekeeping

[taylorhbic]

ive been paying a premium for my insurance for months, trying to find the right doctor and making appointments and just yesterday they told me that hormones wernt covered despite them saying it was. Im at a loss at what i should do now and how to go about getting hormones :/.

[FTMax]

There could be a few different reasons why the hormones aren't covered. You would need to ask them what in your policy justifies the exclusion of hormone replacement therapy.

What kind of insurance do you have? My vote would be to find a GP who's willing to make the necessary referrals or is comfortable doing it themselves. Find out which doctors locally are covered by your insurance and try to get in touch or make an appointment. Explain the situation to them and see if they're willing to work with you.

Hormones themselves are probably the least expensive part of transitioning, honestly. It's the doctor visits, lab work, and surgery that can get up there. If you find a doctor that's willing to work with you, have them code the purpose of your visits as an endocrine disorder.

[JLT1]

My insurance company does this periodically.

1.  Get a detailed copy of your policy.  Specifically,  what is covered.  Detailed.   They won't want to give it to you...

2.  Get, in writing,  the reason it was denied.   Half the time it's a code issue but get the details.

3.  Call the accounting depth of your doctor's office.   Make sure that the diagnosis and treatment is correct,

4.  If it is a code issue, call insurance,  then doctor's office,  then insurance then doctor.  Keep going until it is fixed.

5.  If it isn't and your covered, your plan has an appeal process. Follow it.  Complain to the state insurance board.  Depending on where you live, there are other state offices as well.

If you need help,  PM me.

Jen

[taylorhbic]

i need a tremendous amount of help atm. ive been saving all my money for this and this is just crushing me. I have blue cross blue shield insurance and they said that hormones are "cosmetic" and arent covered. i asked why they lied all this time and they said "im sorry you feel this way" i wanted to lay the ->-bleeped-<- smack on them. The doctors that have dabbled in transgender hrt around where i live cant tell me over the phone for some reason their expertise or even if they prescribe, making going out of network hard.

[Emily E]

Hormones are cosmetic?  You really need to pursue this as HRT is not cosmetic and is a recognized treatment not only for Transgender issues but also for cis females.  I would follow the advice Jen gave and squeak at them down till they give you what you have been paying for. 

[DarkWolf_7]

I have a similar thing that happened to me because I wasn't quite sure how insurances work. But basically the insurance company (in your case blue cross) has different plans underneath them and not all of them cover the same things. I would look specifically at what your plan covers.

Some policies consider transgender services cosmetic while others realize that it is not cosmetic and should be covered.

But max said, if you can get the expensive stuff like lab work, etc. covered by using a different diagnosis code, you could very well afford HRT.

[JoanneB]

My insurance company does this periodically.

1.  Get a detailed copy of your policy.  Specifically,  what is covered.  Detailed.   They won't want to give it to you...

2.  Get, in writing,  the reason it was denied.   Half the time it's a code issue but get the details.

3.  Call the accounting depth of your doctor's office.   Make sure that the diagnosis and treatment is correct,

4.  If it is a code issue, call insurance,  then doctor's office,  then insurance then doctor.  Keep going until it is fixed.

5.  If it isn't and your covered, your plan has an appeal process. Follow it.  Complain to the state insurance board.  Depending on where you live, there are other state offices as well.

If you need help,  PM me.

Jen

Finding specifically what the policy states is no easy task these days. A member of my group is a small business owner. Even she does not have a clue about the details.

With one insurance company I officially started HRT sailed right through, no issues. This year my company changed providers. I've been on HRT for nearly 2 years. Yet the pharmacy told me that A) It's denied because "I am a male" and B) I need pre-approval.

Even the pre-approval route wasn't good enough. That got rejected. Finally a "Doctor to Doctor peer review" worked.

Then finally.... rejected AGAIN. Apparently the rocket scientist there at the insurance company did not like "estradiol vlarerate". It needed to be re-written as Delestrogen. Funny part is the insurance companies very own mail order pharmacy lists EV.

BTW - This very same insurance company also hired my useless brother-in-law.

I just can't wait to see what my anxiety level will reach within the next few weeks as I go back to my doc for blood work, my annual checkup, plus renewing my scrips. Maybe now there is a special note in my file that I am "one of those" and things will sail through

[MugwortPsychonaut]

i need a tremendous amount of help atm. ive been saving all my money for this and this is just crushing me. I have blue cross blue shield insurance and they said that hormones are "cosmetic" and arent covered. i asked why they lied all this time and they said "im sorry you feel this way" i wanted to lay the <not allowed> smack on them. The doctors that have dabbled in transgender hrt around where i live cant tell me over the phone for some reason their expertise or even if they prescribe, making going out of network hard.

I have IBX, and they cover a good chunk of my hormones, so they're obviously BS-ing you. Being that they're from Philly, they're naturally going to have a bad attitude. Do you have access to a TBLG clinic who can advocate for you?

[rosetyler]

Tier 1 CSR for a major US health insurance company here.  Insurance co are ->-bleeped-<-s.  I'm sorry.  :/

Since you're being told different things by different CSRs, get the list of benefits yourself and look through them.  Figure out exactly what you want covered, and what is or isn't covered-the HRT meds themselves, endo visit, PCP visits, labwork, diagnostics, etc.  Are your providers INN or OON?   I can help look through them if you want, and show you where its mentioned.  Let me know!

If they are covered...great.  If not, you should be able to put in what's essentially a specialty exception request.  My department/company calls medication related requests clinical determinations and other types of things organizational determinations.  If your doc puts it in we call it a Prior Authorization (PA).  It's where you or the doc says "look insurance co, the member (you) needs this meds or services because of this reason."

Stay strong.  You can do this.

[JLT1]

Tier 1 CSR for a major US health insurance company here.  Insurance co are ->-bleeped-<-s.  I'm sorry.  :/

Since you're being told different things by different CSRs, get the list of benefits yourself and look through them.  Figure out exactly what you want covered, and what is or isn't covered-the HRT meds themselves, endo visit, PCP visits, labwork, diagnostics, etc.  Are your providers INN or OON?   I can help look through them if you want, and show you where its mentioned.  Let me know!

If they are covered...great.  If not, you should be able to put in what's essentially a specialty exception request.  My department/company calls medication related requests clinical determinations and other types of things organizational determinations.  If your doc puts it in we call it a Prior Authorization (PA).  It's where you or the doc says "look insurance co, the member (you) needs this meds or services because of this reason."

Stay strong.  You can do this.

What is a "CSR"?

Yes, insurance companies are ->-bleeped-<-s. 

Jen

[Alissa16]

Yes; I agree 100% insurance companies are big time a hole plugs!!!.
With the new health care law. I had looked into..I was actually kinda jazzed thinking that now I can get some
help funding my way to womanhood.. Beeep!!Wrong!!.
Yeah, I got the plan write ups and costs, co pays..piles of paperwork gobbledegook!!!
Yep the major insurers have some (somewhat?) affordable policies but;
Looking for hrt,SRS you have to enter into the golden realm of policy premium plans.
Anthem blue cross you will be looking at premiums beyond $700.00 a month!!
Yep!!... Iam still having to foot my own way...progress??

[Emily E]

What is a "CSR"?

Yes, insurance companies are ->-bleeped-<-s. 

Jen

Customer Service Representative (CSR)

[Kitten_Nikki]

I've been looking into mine and hormones are only covered under mine if they're administered in the office. Pills won't be covered most likely except on my HRA.

[Dee Marshall]

Talk to your pharmacist. I have no insurance at all and mine was able to find a way for me to get my estradiol and spironolactone for about $35 every three months. There are all kinds of free programs to help you. Basically, they're customer loyalty plans.

[iKate]

My insurance doesn't cover estradiol pills as I'm listed as a male. However Wal-Mart sells them for $5 for 30 and $10 for 90 pills so I get them there. I suppose I could go fight them since NY governor Cuomo says they have to cover trans care but I haven't bothered. Spiro is covered as blood pressure medicine. Look into getting your scrips filled at a big box store where they have discount programs. Walmart, Costco, target.

The visits themselves are covered as primary care visits. I get my HRT and primary care integrated together.

[Sydney_NYC]

I received an updated policy book from my insurance carrier yesterday (NJ Health Republic) and they added SRS and HRT in the exclusions area and it wasn't there several months ago when I switched to them. I'm pretty upset about that, but I kept a copy of the original policy where it wasn't there so I might be able to do something with that, but I doubt it. They are covering my HRT meds, but only because I'm listed as female in their system (did my legal name and gender change last June), so it just looks like standard cis-woman HRT for a 43 year old woman.

[iKate]

I received an updated policy book from my insurance carrier yesterday (NJ Health Republic) and they added SRS and HRT in the exclusions area and it wasn't there several months ago when I switched to them. I'm pretty upset about that, but I kept a copy of the original policy where it wasn't there so I might be able to do something with that, but I doubt it. They are covering my HRT meds, but only because I'm listed as female in their system (did my legal name and gender change last June), so it just looks like standard cis-woman HRT for a 43 year old woman.

My work policy specifically excludes bio identical HRT and all "sex change procedures." It's UHC and CVS Caremark which is awful and even denied my sick few months old daughter her asthma medicine. I'm on my wife's plan which is NYC government employees (EmblemHealth for office visits, BCBS for hospital, innoviant for scrips) but I don't know how long I will be on that.

Since you're on an ACA exchange program don't they have to cover some stuff? I am not sure how that works.

My HRT visits are covered as primary care and the pills I pay $10/mth out of pocket at Walmart.

[Sydney_NYC]

Since you're on an ACA exchange program don't they have to cover some stuff? I am not sure how that works.

Not for NJ. The American Health Care Act only prevents insurance companies from using pre-existing conditions to deny claims because of HRT. Since you are in NY, NY does have a state law that they can not exclude SRS and HRT. This only happened last December so it's possible your wife's insurance company has updated their policy. I would call them and state that they are breaking New York State law on denying you HRT coverage.

The only other states that all insurance companies must provide transgender healthcare is: CT, CA, CO, OR, WA, IL, MA, VT and DC  (and of course NY).

[iKate]

Not for NJ. The American Health Care Act only prevents insurance companies from using pre-existing conditions to deny claims because of HRT. Since you are in NY, NY does have a state law that they can not exclude SRS and HRT. This only happened last December so it's possible your wife's insurance company has updated their policy. I would call them and state that they are breaking New York State law on denying you HRT coverage.

The only other states that all insurance companies must provide transgender healthcare is: CT, CA, CO, OR, WA, IL, MA, VT and DC  (and of course NY).

I am actually in NJ but she's a city employee so the plan supposedly is a NY plan.

[Sydney_NYC]

I am actually in NJ but she's a city employee so the plan supposedly is a NY plan.

Because it's a NY State policy, the NY State rule applies even though you live in NJ like I do. Kind of makes me want to move my residence to NY just across the water. I just don't know if the additional taxes for that would be worth it.