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Dear fellow Kossacks,

Short diary. Wondering if someone can help me with the following:

Anyone familiar with California insurance law?

My mother was recently switched to a plan called Medicare 65+, managed under Blueshield of California. She has primary Medicare, then the Blueshield under my father's policy and also has her own PPO insurance.

She recently received a letter that her Januvia would no longer be covered under Blueshield.

She needs Januvia for her diabetes care and it is incredibly expensive. However, for the very brief period I had diabetes, before my weight loss, Blue Shield of Connecticut played games with me, saying I'd have to pay for my Januvia, $600 a bottle, myself, then get reimbursed. Then, after many phone calls, they suddenly remembered there was a state mandate to cover diabetes supplies in Connecticut. Suddenly, when I mentioned that, everything was great.

I know California has a similar such mandate:
Equipment, supplies (including prescriptions if prescription coverage is included), and self-management training for the management and treatment of diabetes.

My question is, can they get away with no longer covering her Januvia or can I refer to this mandate? As far as I know there is no generic for Januvia.

If they do not cooperate, what avenues should I pursue and to whom could I file a complaint in California?

Any thoughts or advice would be greatly, greatly appreciated!!

Originally posted to gladkov on Thu Feb 14, 2013 at 05:40 PM PST.

Also republished by Kossacks helping each other.

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Comment Preferences

  •  Medicare Rules Differ (4+ / 0-)

    Her insurance seems to be strange. PPO? Why, it doesn't fit in.

    Most people on Medicare get Medicare, Medicare supplement and Part D (drugs). Others have a Medicare Advantage program that includes Medicare and supplement (and, often, Part D).

    Medicare supplement or Advantage have standardized options. Part D is the one that you have to review to make sure the drugs you are taking are covered, but you have the option of deciding which Part D coverage you want.

    I cannot address Cal specific questions, but the Medicare rules are genererally not changed by state.

    Americans can make our country better.

    by freelunch on Thu Feb 14, 2013 at 05:56:41 PM PST

  •  call your state insurance commissioner and (5+ / 0-)

    complain; it appears she may have been "slammed" into a Medicare+ program or an HMO.  Call Medicare and determine if she is still covered as joining a Medicare+ HMO means you have opted out of Medicare and are now under the HMO's rules, not CMS' s rules.

    I strongly suspect she was slammed as MC+ programs here paid a kickback to pharmacists to sign up pts for the program and created all sorts of a mess when elderly pts could not understand that they were opting out of traditional  MC.  BC may have moved her to a MC+ HMO unilaterally  

  •  BS of CA/California Physicians Service (2+ / 0-)
    Recommended by:
    Villanova Rhodes, dejavu

    is regulated by the Dept. of Managed Healthcare.  You should notify them at Help Center, 1-888-466-2219.

    "To recognize error, to cut losses, to alter course, is the most repugnant option in government." Historian Barbara Tuchman

    by Publius2008 on Thu Feb 14, 2013 at 07:03:20 PM PST

  •  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.

  •  Since she has two policies under Blue Shield, (2+ / 0-)
    Recommended by:
    mskitty, dejavu

    you might want to figure out which policy sent her the notice. It's possible that the other Blue Shield policy has primary liability, and Januvia is covered under that policy. Insurance companies are really good at getting out of paying claims.

  •  Tangled mess (0+ / 0-)

    This is a tangled mess. She cannot have three insurance plans. No one can. Otherwise, she could submit for reimbursement from three plans. Is an agent involved? This is what can happen with someone can go online and shop for their own coverage and have no clue on what they are buying.

    Is she still working and paying a premium for a PPO plan?

  •  Call the SHIP too! (1+ / 0-)
    Recommended by:

    Every state has free information from people who are guides, mentors and advocates about Medicare and its associated insurance and costs: This is the link at the Medicare website:(  The California SHIP is called California Health Insurance Counseling & Advocacy Program (HICAP) and their number is (800) 434-0222. The best call would be from somewhere near your mother, since you should be directed to local HICAP counselors who may have heard the whole thing before, and know just what to do.

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