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View Diary: Need your help Kossacks! - Know CA insurance law? (9 comments)

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  •  Januvia is listed as a Tier 2 drug (4+ / 0-)
    Recommended by:
    FG, wilderness voice, grover, mskitty

    in the Blue Shield formulary for at least several CA counties. Check here to see if you can find the formulary that applies to your mother:

    BS of CA

    If it's in the pertinent formulary, perhaps there's a dispute about whether she needs it or can get by on a cheaper drug. When we had a similar denial of a drug by my mother's United Health Part D plan, the denial letter was very specific about how to appeal. A letter from her doctor did the trick, for a year at a time. Your mother's doctor should know about any mandated coverage.

    Your description is a little confusing, given that Blue Shield is involved in two different ways with your mother's coverage and she seems to be in both an HMO and a PPO, which seems odd but I'm no expert. To get an answer from the state regulators, you may need to figure out just how the three policies relate. It's hard to do from a distance, but if you can get copies of any denial and of her proofs of coverage, you'll be better able to do some digging.

    Records often get screwed up as to which coverage is really primary, and then there's a general scramble to say "no, that other company is supposed to cover it, not us!" Be aware that your mother may need to file an authorization form to permit you to speak to anyone directly on her behalf if you're not already acting as her agent. Good luck.

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