I’ve recently shared with you how the unpredictable costs healthcare — even with Obamacare — has burdened my family business, a U.S. manufacturer that employees hundreds. Here’s my story and what I just I’m about to mail New York State Attorney General Eric Schneiderman. My insurance is PPO and better than many plans that are out there; the industry is and always will be the problem. Defending President Obama’s legacy doesn’t mean defending the system. He started us on the road to further and more meaningful change. Here’s my letter:
Blue Cross Blue Shield of Michigan delayed and obstructed prior approvals for medication (Cimzia) that I need to live and work in treatment of the autoimmune disease Ankylosing Spondylitis. I was informed today, 1/27/16, that the drug was approved; however, that outcome was only achieved after threatening to take legal action against the insurer. What happened to me shouldn’t happen to anyone and I hope my experience can help others.
Earlier today, [redacted], the specialty pharmacy that is handling my case on behalf of [redacted] at [redacted], was told that a courtesy appeal will be undertaken and completed this week using updated information with consideration that I have taken Enbrel, as per BCBS’s stepping process. However, Blue Cross’s customer service told me earlier today to write to request an executive appeal without any promises on how long a resolution would take. It said that I may not submit a prior approval for the same drug more than once within a two-year period. Blue Cross only acted after I mentioned writing this letter to the state.
This has been a long, drawn out, and harmful process. There was a previous denial for Cimzia in September for a prior authorization that began in August, where[redacted] and [redacted] had to send in forms 3-4 times to get a response, prior to it being denied. Then, Blue Cross gave me contradictory information about the appeals process, which I gave up on after being told over the phone it could take up to another 90 days. That turned out not to be true. The approval for Enbrel, its preferred drug that I took in place of Cimzia, was efficient and without and problems.
A prior approval administered by [redacted] several years earlier for another preferred drug, Humira, was also without any incident or delays with BCBS processing or receiving paperwork.
During the time frame leading up to and after September (the first prior authorization), my autoimmune disease progressed into my spine, and I missed significant time at work and other consulting projects that reduced my income. I also developed severe GI problems - with weeks of Irritable Bowel symptoms - while taking Embrel, resulting in an endoscopy, colonoscopy, and treatment with more drugs. Enbrel failed, and [redacted]made the decision to once again prescribe Cimzia for a second time, after following the preferred order of drugs therapies.
A prior authorization form was faxed to BCBS by [redacted] on January 13th, 2016. I called into Blue Cross on Jan. 20th, and was told there was no decision made, but to expect one this week of 1/25/16. I called again on 1/26/16 to follow up, and was told that there was no prior authorization found within the system and to have [redacted] call in. The pharmacy department at Blue Cross refused to speak with [redacted] when it did call, even to confirm the resubmission of yet another prior authorization that [redacted] sent via fax on 1/26. All that was on record was a denial from earlier this year from before I tried Enbrel. The new submission(s) were not.
[redacted] told me and said that it “hears a different story every time [it calls Blue Cross] and that this prior approval process is the most difficult that it has handled in all its cases. [redacted] went as far as to suggest that I should seek alternate insurance coverage.
I’m currently under bi-weekly treatment with a methylprednisolone, which when combined with the budesonide that I am taking for the IBS that began with Enbrel, resulted in severe GI complications and a CT scan to evaluate for pancreatitis. I’m still having painful arthritis flare ups that have prevented me from engaging in social and most physical activities.
Blue Cross has refused to deliver the care that I need and has engaged in deceptive behavior that is not within the spirit of honoring my health insurance contract. It is my belief that its duty of Good Faith and Fair Dealing hasn’t been upheld.