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I'll have a Blue (crossed) Christmas...

I just got a phone call from my pharmacy. It turns out that a prescription I had dropped off needs written permission from the doctor before the insurance company will authorize payment.

Stupid me. I thought that's what a prescription WAS -- the doctor saying in writing that she wants me to take this particular drug -- but apparently, to Blue Cross of California, that isn't sufficient. Naturally, neither my doctor nor BC's customer service office are available on weekends, so I get to wait until Monday to deal with this particular issue. But I'm already imagining on just what might happen.

Update: Apparently there is some confusion about my situation. First, the prescription is NOT THAT TIME-SENSITIVE -- waiting to start a couple days won't kill me, or even cause me more than a smidgen of annoyance. If it was, I'd get on the doctor's answering service immediately. Second, everything below this is strictly fictional and satirical -- every word is false, including "and" and "the." I greatly appreciate the concerns, folks, but please, don't waste it on me -- save it for someone who NEEDS it. And thirdly, Hunter, the problem isn't the pharmacy. They'd gladly give me my meds right now if I paid full price. The real swine here is the insurance company.

"Blue Cross, how may I help you?"

"I have been told that to get a certain prescription filled, I need written permission from my doctor. I thought that was what a prescription slip was."

"No, sir, that is not sufficient. We need the doctor to fill out a AOPS-17 form before we will authorize payment."

"AOPS-17? What's that?"

"Affidavit Of Pinky Swear. It's the doctor saying that she really, really wants you to take the medication."

"OK... but is that absolutely necessary?"

"If the doctor is unavailable, then you can fill out and fax in a form CMH2TD to us directly. That's a 'Cross My Heart, Hope To Die' declaration that the doctor really did tell you to take the medicaiton."

"Can you fax me a copy?"

So I fill out the CMH2TD and fax it back, then head off to the pharmacy. There I find out it's still being denied. I call back.

"My prescription is still not being covered, even though I sent in a signed CMH2TD form."

"Did you also sign the SNIME Codicil? Because we cannot process CMH2TDs without the SNIME Codicil attached."

"No, I wasn't sent anything about SNIME. What is that, anyway?"

"That's the Stick a Needle In My Eye clause. CMH2TD forms are invalid without them."

(sigh) "Can you fax me one of those as well?"

So I sent it off, and went back to the pharmacy. Denied again.

"Blue Cross? I sent in the SNIME, but I was still denied."

"Did you send it by itself?"


"I'm sorry. Our policy is to discard any SNIMEs that come in without an attached CMH2TD."

"Can't you just find my original CMH2TD and put them together?"

"No, those are discarded, as well."

Luckily, I still had my originals of both, so I sent them in together. Then I trekked back to the pharmacy, where they finally filled my prescription.

One week later, I get a letter in the mail from Blue Cross. It's a Form SDS-12, denying my previous prescription coverage. Also in the mail is a bill from the pharmacy. I call Blue Cross again.

"Blue Cross, how may I help you?"

"Yes, I just received a Form SDS-12 in the mail, along with a bill for a prescription I had filled a week ago."

"Yes, sir. That's the 'Simon Didn't Say' form. We have determined that your prescription should not have been covered."

"Couldn't you have decided that BEFORE I picked it up?"

"Tell you what, sir. I can file a OTDO-18 -- that's a 'One-Time Do-Over' -- and we'll cover it this time. But in the future, you will need to submit a SS-23 three days in advance or your prescription will NOT be covered."

"SS-23. That would be the 'Simon Says' form?"

"That is correct, sir."

So I finally get all the paperwork done and happily take my medication. But three weeks later I go for a renewal and again I am refused. I call them back.

"Blue Cross, how may I screw you?"

"I beg your pardon?"

"Blue Cross, how may I help you?"

"I just went for a renewal on my prescription, and it was denied."

"Let me check on that... oh, I see the problem, sir. You shouldn't be out of the pills yet."

"Huh? I got a month's supply, and it's been four weeks. They're all gone!"

"But our files indicate no MMI requests from you. Without those requests, you should not be actually taking those pills."

"MMI requests? What are those? I've never heard of that."

"Those are the 'Mother May I' requests. You need to make them to us before you actually take any medications covered by your prescription plan."

At that point I made an appointment with Dr. Kevorkian. If ANYBODY takes Blue Cross of California, it's gotta be him. And after my appointment, I'll let BC-CA fight with my estate. I won't care any more.



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Comments (23)

I can belive that. They do... (Below threshold)

I can belive that. They do everything they can to keep from spending money.

Had problems some years bac... (Below threshold)

Had problems some years back trying to get BC of NY to play nice with BC of Connecticut.


Been quite happy, with Aetna, ever since.

I'm a Pharmacy tech and thi... (Below threshold)

I'm a Pharmacy tech and this happens all the time. The drug probably isn't on their formulary so they need to know why you are taking it and if you've tried other drugs before this one and if so why they didn't work. There is probably another drug that works the same way that is on their formulary and want you to use that one. It depends on the doctor if he/she wants to go through the aggravation of pre-authroizing the medication of if they want to switch it to one on the formulary. Good luck, as this is a real pain in the butt for the pharmacy and the doctor.

Agree with dee. My first re... (Below threshold)

Agree with dee. My first reaction was that the insurance company probably red-flags all non-generics, and hopes your doc will go along. Anyway, when in doubt, Blame Canada.

Your pal

Personally, I prefer the ev... (Below threshold)
Remy Logan:

Personally, I prefer the evil HMO down the street. I've had very good experiences with them.

- With enough time and stal... (Below threshold)

- With enough time and stalling eventually the whole thing will be wonderfully resolved Jay when you fill out the *IYDGMMFMIGTBUTPOSP-51a form which doesn't work but when they haul you off to the slammer you can get your meds from the prison Doc directly....Your tax dollars in action....

- * IF you don't give me my fucking meds I'm goint to blow up this piece of shit pharmacy -

Jay, your scenario is VERY ... (Below threshold)

Jay, your scenario is VERY funny, but your predicament is NOT; I hope it gets resolved first thing on Monday.

Jay:Welcome to my ... (Below threshold)


Welcome to my nightmare. I quit civilian medicine 8 years ago in Tennessee after dealing with over 27 different Medicaid programs, HMO's PPO's IPA's [go ahead, you can up with some great explanations for these acronyms] telling me what drugs I could and could not use. To treat cancer and serious blood disorders! In an office of 5 doctors we had 3 people employed full time just to manage the insurance approvals (not the billing per se).

Now I work for the Uncle Sam, and have only one insurance company to deal with - Tricare (well, actually there are different Tricare programs in different regions, but I only have to deal with one at a time). I still have to deal with the hassles, but from only one source, and for the most part they are in an office down the hall.

The "managed care" pharmacy works just as described by other commenters: hassle the docs to prescribe the meds that the insurance doesn't want to pay for, (don't forget that since the docs are paid less under "managed care" they are working harder - seeing more patients in less time -- to keep profitable) so they are more likely to take the path of least resistance. How do pharmacies pick what drugs on on their formularies? The bottom line of course. Whichever drug company will lowball their bids. Not much emphasis on quality, though they are very careful to document that there is no problem with switching to "equivalent" drugs. Since the formulary changes on an annual basis, you have to switch patients from one to another when the formulary changes. Or fill out all those forms you mention.

The only studies I've seen about managed care formularies suggest they actually cost more money when you factor in the extra doctor visits for all the folks having to be seen before and after their meds are switched, and managing the 5-10% that then have some sort of adverse problem (new drug doesn't work, new drug causes side effect, etc.). But they do control the pharmacy costs, which managers see at the top of their cost bundles, so they continue to be popular.

As an aside, our hospital isn't funded enough to pay for all the care requested here. The pharmacy is the big cost over run. So recently they just dropped some of the big cost drugs off the hospital pharmacy entirely. Since there is a Tricare Mail in pharmacy benefit, and a benefit for going to a local pharmacy for stuff not on formulary, the patients get written scripts from us to fill in the mail (or faxed from OUR office) or downtown. Course this actually costs the government more in the long run, but it keeps the hospital afloat for another fiscal year.

Maybe one of the reasons you had problems with your prescription is YSTFIFTDO -you're supposed to fax it from the doc's office - not your home or your office. Don't ask why.

Good luck and best wishes for your health.

Sounds like accountants prc... (Below threshold)
Fred Boness:

Sounds like accountants prcticing medicine. Is that legal?

I would 'spect this post al... (Below threshold)

I would 'spect this post alone shoulda been sufficient evidence to the insurance company that you were in desperate need of bein' heavily sedated or somethin'. J/K o' course. ;)

Welcome to the world of pri... (Below threshold)
Jesse Malkin:

Welcome to the world of prior authorization requirements. I'm guessing that the drug you have been prescribed is (a) similar to other drugs within the same therapeutic class but (b) much more expensive tha the others. Though PA requirements can be abused by insurers they are for the most part a reasonable cost containment mechanism that help control pharmacy costs with few, if any, adverse health effects. Here are a few examples:

- If you are at low risk of GI problems and have not yet attempted Motrin or some other NSAID, it is reasonable for an insurer to impose a PA requirement on Celebrex and other COX-2 inhibitors.

- If you have not yet tried OTC Claritin, it is reasonable for an insurer to impose a PA requirement on prescription antihistamines such as Zyrtec, Allegra and Clarinex.

- If you have not yet tried OTC Prilosec or OTC Zantac or OTC Tagamet, it is reasonable for an insurer to impose a PA requirement on Nexium, Prevacid and other prescription proton pump inhibitors.

- If you have not yet tried generic Prozac (fluoxetine) or generic Paxil (paroxetine), it is reasonable for an insurer to impose a PA requirement on brand name antidepressants such as Zoloft and Effexor.

Do PA requirements interfere with the doctor-patient relationship? Yes. Do they occasionally create a hassle for patients? Yes Do they create some risk of adverse health effects? Yes. But these costs are small relative to the savings, which can be substantial.

For example, insurers can buy generic Prozac for a few pennies per tablet, whereas brand name antidepressants like Zoloft and Effexor cost more than $2.00 per tablet. So switching a patient from Zoloft to generic Prozac can result in savings of around 99%. The effects of the two drugs are somewhat different, of course, but there is no evidence that one is better than the other so why not start with the cheaper one?

If you want zero risk, pay out of pocket and get whichever drug your doctor recommends. If you want your insurer to pay, however, you shouldn't be surprised to see some pushback every now and then.

Many times what an i... (Below threshold)

Many times what an insurance company does is in your best interest.

There is wide regional variation on how the same disease is treated by doctors. That means that some patients are getting the best treatment available and others are getting poor treatment.

As a consequence, Insurance companies, using medical experts, have established best practices for treating every disease. The patient benefits because your doctor is forced to used best practices or explain why. Your doctor has varied from a best practice so he has to justify it with another form.

Also, there are drugs that give 4% better chance of a good outcome but cost 10 times a much. Should insurance companies pay for such drugs-I don't think so.

Employers must reimburse insurance companies for every dollar they have paid out over a 5 year period. Economics dictate that every dollar paid out in health care costs is subtracted from the dollars paid to employees in wages.

So employees benefit from insurance companies insisting on the most cost-effective treatments.

THe procedures can b... (Below threshold)

THe procedures can be a pin in the neck. I am on a BCBS plan. It is a nationaly group plan. THe claims still get initially filed through the local BCBS affiliate. In this case it was BCBS TX.

I had some tests done. The tests were sent to a specialist for evaluation/interpretation.

I got a Statement fo Denial from BCBS of TX. I am not covered by BCBS of TX. I got billed. I called the specialist office and asked how they filed the calim and whether they used the correct information. I called my BCBS carrier and was told that they had never received the claim and that the doctor's office needed to refile the paper work. I called the docto's office and they said that I needed to call BCBS of Texas and resolve it. They filed the work correctly. I told them what my carrier said and they said they are not willing to refile the claim.

The hospitol, and personal physician are going throing the same claim procedures and have been paid. This Specilaist office has tried to dodge my polite phone calls.

I share you frustration.

Um - sorry to go off-topic,... (Below threshold)

Um - sorry to go off-topic, but have you seen this??


From this LGF post::

Re: Daily Kos and other liberal blogs are now officially CHEATING on the 2004 Wizbang Web Awards:

* * * *

Some comments from Kos Readership :

This poll [2004 Wizbang Web Awards] is so non-scientific it's funny. Not only is it not scientific, it's poorly coded ... as in, worse than Diebold. I've voted a couply thousand times today thanks to a a little PERL script I wrote (posted above). I'll get Atrios and JMM some votes once DailyKos moves into 1st

By the way, that Perl script rocks. I turned it into a 200-vote loop voting once a second. Let's see if they find me out. Heh heh heh.

* * * *

Go see for yourself. The liberal blogs just opened-up big leads in the Wizbang 2004 Web Awards under best blogs.

The hacking of a contest by the lefty blogosphere!

They're self-admitted a-holes - and proud of it!!

I live in NY State. Not to... (Below threshold)

I live in NY State. Not too long ago my company switched to BC-CA. Why CA I haven't a clue other than $. My coverage went down, my costs went to the moon. Your situation is precisely why I dumped them and bought my own.

That is absolutely hilarity... (Below threshold)

That is absolutely hilarity! My guess about BLUE CROSS it's headquartered in a blue state, like California??? And, Blue Cross is a model for governmental takeover for Hillary/Kerry Care, right? Hah!

I just love the precise ans... (Below threshold)

I just love the precise answers from jake and jesse. Sorry folks, but if you see a whole population of patients, you know that some drugs work better than others in some folks but not others. I love the big brother approach to medicine they also promulgate: "we the experts know best how to treat the problem, so do it our way or its the highway." Maybe that's why they call it BLUE cross.

Lets take allergy treatment as an example -- allergic rhinitis to be specific.

While Claritin is the cheap one now, it used to be the expensive one and Allegra cheaper, for example. I've had to switch a horde of folks back and forth on these drugs each Spring as the costs of the drugs change. Yet if anyone bothered to look at the cost of all the doctor visits necessary to a) change the medication b) re-evaluate the patient after a trial of the new drug c) deal with folks whose trial doesn't work and they get worse I suspect that the savings over all go way down -- as confirmed by studies done by managed care entities and promptly forgotten.

Now there are much more effective first line therpies for allergies -- avoidance, hygeine, topical nasal steroids, nasal saline lavage for example, (not to mention desensitization -- allergy shots) that all cost a whole lot less than non-sedating antihistamines in the short or long run. I just love hearing form folks who have allergies (or kids with asthma) who have several pets they are allergic too, but won't get rid of the pets, and want me to spend my time, and the insurance company to spend their money, on the medical problems they have because of their allergies to their pets.

If doctors or patients aren't spending time on these, is it the pharmacy's job to police the docs, the insurance company's, the patient's, medical licensing or the medical establishment's job to police this. Maybe a little of each. Right now, though the insurance programs and their formularies wield most of the power.

My grand solution for this and most of the cost related problems in medicine is to change the reimbursement process and put the dollar control in the hands of the patient.

If you want "insurance" for medical care, you get a credit card like account with a fixed amount of money a year (or month) you can spend any way you want (meds, doctors, tests, "alternative" medicine), but after you've spent that amount, you are on your own unless a catastrophic illness occurs, when a higher limit is invoked. If you don't spend any money you get either a credit on future premiums or a proportion credited for higher limits inthe future (carrot for not utilizing). Specific limits can be created for chronic diseases that aren't quite catastrophic.

Anyways, once the patient has to figure out how much and how they want to spend, they'll have some motivation to modify lifestyles before utilizing medical therapies to treat allergies, hypertension, hypercholesterolemia, acid reflux -- all big time dollar cost in most pharmacies.

Using this scheme, the insurance companies just cut out a huge administrative cost for themselves, and doctors costs for billing insurance companies also drops astronomically.

Right now you have little financial motivation and no control. Just a big hassle for patients and doctors.

JYour story may be... (Below threshold)
Dr T:


Your story may be "fake but accurate".

I performed an in office procedure on a patient, the cost $1800. His BC plan was from another state, so they would not pay me directly. They sent the money to the patient, who then refused to forward the payment on to me. I then had to send him to collections, but he left town....no payment for services performed by Dr T. Patient gets service & a nice cash bonus!
This happens to my Anesthesia friends all the time.
It's the insurance carriers way of saying 'you should have a contract with us directly.'

This kind of practice helps drive a wedge between patients & doctors.

Dr T

For a more positive take on... (Below threshold)
Ken Hirsch:

For a more positive take on insurance companies managing drug prescriptions, see this Malcolm Gladwell article from the New Yorker.

epador knows the score and ... (Below threshold)
Doc Jim:

epador knows the score and Jake and Jesse are blowing smoke. There are savings to be made from selection of medications within one type of medication. BUT it costs a great deal of EXTRA time for the doctor and pharmacy to sort out many of the procedures.

Most of the calls for pre-authorization that I make are received by a clerk; mostly they are just putting out a hoop for the doc to jump through. That reduces the number of pre-authorizations by hassling the DOC. Simple systme, it works.

I agree that a "credit card" approach and a 30 day trial for each new medication makes a lot of sense. The patient discusses with the doc the next visit about a cheaper medication. It can be administered just like current pharmacy benefits. The patient can bring the sheet from the pharmacy/insurance plan on that next visit---detailing the
"cheaper alterenative."

The big, big problem is the change in the pharmacy listing. Next quarter, they have a better contract on Lipitor than Zocor, so Zocor no longer is approved without DOC spending time on phone.

I am under a BCBS ppo plan.... (Below threshold)

I am under a BCBS ppo plan. Payment is made directly to the doctors. THe provider in question is a PPO provider of BCBS. THe way the system works is that there is a three letter prfix to the patients ID code. This prefix is used to identifiy the actual insuriance carrier.

The local provider send the claim to the local BCBS Affiliate for processing they forward the claim through the network. The actual carrier will authorize payment. They payment comes form the LOcal BCBS (inthis cas BCBS of TX).

THe patient should never have to file a calim and the payment always goes through the network to the BCBS provider.

In this case my employer switched BCBS form BCBS of TX to another BCBS provider. THe claim form was incomplete and the BCBS of TX attached the claim to the old POlicy instead of recognizing that the calim under oanother BCBS affiliated carrier.

Again under BCBS PPO plans,, payment is made to the Participating Provider.

I have no deductibles for in network care.

I would be for the c... (Below threshold)

I would be for the credit card approach if all the doctors had to publish the prices for everything they do on their internet site.

That would enable us to shop for the most cost effective doctors.

For what it's worth, Mr. Te... (Below threshold)

For what it's worth, Mr. Tea, I have some inkling of what you've been going through. In March of 2002, while visiting my father, I had a seizure. Unfortunately, I was without health insurance at the time, being young and in good health (so I thought), and having a job interview the next day, ironically enough.

Suffice to say that since then my life's been a living hell of having to deal with the Minnesota managed-care "We're here to help!" system, and it hasn't been any fun at all, with neurosurgery and repeated seizures, various drugs and prescription changes, and now I get to re-negotiate my coverage, which has apparently expired without my knowledge, since I had the temerity to finally get my life back together and get a job (no easy feat when you live in the suburbs and have a medically-suspended license with a poor mass-transit system).

Now, if there was a Cat-Health option, I wouldn't have minded that at all. Unfortunately, my epilepsy drugs run out this week, and dealing with Medica is no fun at all. Gonna have to suck it up and pay hard cash. Oh well, such is life.






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