Help with Drug Denial Form

[JoanneB]

Any advice out there on what to say on an appeal form as to why I should not be denied my HRT?

I'm now 3 months into all sorts of BS with Horizon BCBS gatekeeper Prime Therapudics. Last year they initially denied my HRT but after a Peer to Peer review gave the OK.... for a year. So this year I figured some 3-4 months ago to expect the same dance this year

NOT

Now there is some "Appeal" I must file to say why I disagree with their decision to deny me on "Age or Gender" for my estrogen. Hard to say and fight against their decision not knowing what it is based on.

Third phone call in to them now to get in writing the exact policy provision or criteria they used to say no. That started 3 months ago with each time being told "We should get you out something within 10 days".  OK 10 business days or better then 2 weeks, plus life getting in the way of the follow-through. Nothing yet, nor am I really expected this third time to be a charm

During the last call to them on Friday they also said they never got anything from my doc and there never a Peer-Peer scheduled. This is odd because his office admin said she put in the request and it was in the works between them and my doc to schedule a time. Last year the whole thing was cleared up in a week without me ever having to get involved. In fact didn't know what happened till it was all over.

I email my doc, basically asking "What's Up Doc?" I get this form from your office saying I need to fill it out. I'm far from the person to know what to put down on it besides it was approved last year and nothing changed to say I don't need it. Prime THeraputics is hoping I shut and go away when pressing them as to why I was denied. And BTW, they also said no review was ever done. I also mentioned how after a lot of digging I found out from Horizon my work policy has the expected Trans Exclusion.

His response, you're screwed due to the trans exclusion. Nothing I can say or do can help. Yet somehow with nothing else different it went through last year?

Next email in the list from his office. "I'm closing shop in NYC & NJ and moving to sunny south Florida next month".   So I guess he's been too busy packing to make any phone calls or even be bothered to fill out my form for me 

With only a single 90 day script whose 90 days is about over I'm triply screwed. And can't be mad about it since my annual is in a few weeks and my last chance to get a script for a year or so of refills till I find a substitute, if ever. <rant>This is BS I get for trying to do things the right way, why bother?</rant>

[AnxietyDisord3r]

They are giving you a run around because it's against the law (but not yet robustly enforced--you kind of have to go to court which costs more than the drugs do) to deny HRT based on gender under Title VII of the Civil Rights Act. Also, they may be under compliance as of the end of July or the beginning of January to cover HRT under HHS rules. Just one more nasty runaround until they face the inevitable. Godspeed.

[Dena]

I am on Blue Cross/Blue Shield of Arizona with a private policy, $600+ a month payment and a $3500 deductible and they just reworded the trans exclusion policy to make very sure they don't pay for anything. My voice surgery wasn't covered last year and my HRT care isn't even being applied to the deductible. So far they haven't paid out a cent for any of my medical care in close to 5 years. Not much point in me fighting it because in a few months I go on medicare and then I discover a whole new set of rules.

Blue cross used to be the gold standard in insurance but now I think it's the gold brick standard in insurance.

Unless your work policy is changes, I suspect you have few options. Also, if you are using your work policy, I suspect you may be out at least in the section of the company that handles the insurance policy which should be personnel.

[DawnOday]

My voice surgery wasn't covered last year and my HRT care isn't even being applied to the deductible. So far they haven't paid out a cent for any of my medical care in close to 5 years. [/quote

Just curious but how much are you spending on HRT? As I too may be on the hook for it.

[Kitty June]

Check out app "good rx" it makes my patches cost about 50 a month at Walmart. Or about 24 something a box.
That might help make it cheaper
Good luck

[Dena]

My voice surgery wasn't covered last year and my HRT care isn't even being applied to the deductible. So far they haven't paid out a cent for any of my medical care in close to 5 years.

Just curious but how much are you spending on HRT? As I too may be on the hook for it.

I checked it out on goodrx after my first go round at another drug store and on tablets, I just purchased a 6 months supply for $20 without insurance at Walmart. The cost is in the blood test and the doctors visits which I have paid about $800 out of pocket so far. Most of that was the initial visit of $500. Additional visits are $100 with labs making up the rest.

I am on a half transition dose and I suspect as yours may be low dose, the cost should be the same or less.

[JoanneB]

I 'Outed' myself to HR a few weeks back when I went into Social Justice Warrior mode to point out how in spite of all the glowing platitudes in diversity policies and corporate BS, our insurance has an exclusion against a protected class. - The followup is still evolving.

I do shots. According to the best I've found it's close to $200 for 90 day. Blood workup at it's totally astronomical price so far was covered.