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Old 11-30-2015, 05:33 PM   #21
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This saga sounds very similar to the "journey" my DW had trying to get a Prolia shot for her osteoporosis which was prescribed by her endocrinologist.
She either had to pay out of pocket for the shot and then take the vaccine to her physician, to administer but her physician could/would not get the shot as they could not get it in a single use volume and would not order. For whatever reason a pharmacy was not authorized to administer the shot. The shot is a straightforward intermuscular injection.
This shot is a 900-1000/injection event but supposedly would still cost us 4-500.
More research on our Medicare indicated if the shot was administered by her prescribing physician in his office, it was FULLY covered. Despite it being a 150 mile roundtrip to the specialist, it was mileage and time well spent.
As others have posted, many times the first answer you get on coverage does not get you the details required to get the results expected.
Hard to believe the medical delivery system is such an imperfect process.
Nwsteve
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Old 11-30-2015, 06:00 PM   #22
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Many years ago I had a shot in the hospital that cost $600. I was told the insurance will only cover it in the hospital or in the doctor's office. I looked up the same shot today, now the price is $3200.
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Old 11-30-2015, 06:13 PM   #23
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My guess is your dispute is being treated like a complaint. Appeals are different, more formal, and subject to some regulation.
Yes.

Don't waste your time with emails or phone calls.

There should be a pointer to info on the "official" appeal process on your EOB. Submit in writing. Wait a long time. Receive a written answer specifically addressing your appeal. If not satisfactory, follow instructions to the second level. DW appealed a payment situation with her plan a couple of years ago. We learned that other than a call or email to determine if a quick fix is possible or not, it's best to just go straight to the written appeal process. She won. BTW, Her situation was a HMO-like Medicare Advantage plan and involved getting prior primary doc consent similar to your situation.

Again, phone calls, email complaints, etc., all a total waste. Don't whine, appeal. I don't think anyone on the BCBS food chain below the "appeal dept" folks (who work within gov't reg guidelines) are authorized to make changes.

BTW, I have BCBSIL F as a Medicare supplement and they have been champs. 3+ years in, no complaints so far. Expensive but I never get a bill for anything. Just EOB's showing nothing due. I haven't tried a Shingles shot yet though but it sounds like a good idea.
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Old 11-30-2015, 06:38 PM   #24
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Whatever, the shot's worth spending the money.

When my wife and I went to Vegas/Hawaii/San Francisco for the month of February, she was itching terribly on her face and neck. Luckily, she had some Neurotin that minimized the itching. Upon her return, her skin started peeling like a sunburn would peel off.

We later realized she had the shingles, and because she had the shot 18 months earlier the case of shingles was very much diminished. She didn't have the excruciating pain most have with shingles.
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Old 11-30-2015, 06:50 PM   #25
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After hearing what one of my coworkers went through with shingles, I gladly paid for my own shot at age 51.
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Old 11-30-2015, 07:13 PM   #26
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Just another data point:

I got my shingles vaccination this year (age 53 at the time) and it was covered by BCBS (Ohio, not Illinois).

Of course, it was administered at my PCP's office so I guess he approved it...
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Old 11-30-2015, 07:21 PM   #27
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DH, age 60, just got his shingles shot 2 weeks ago. It should have been simple, but no……..

Do you have a minute?

I called our insurance company a few weeks ago to make sure this was covered and how to proceed. Yes, it's covered without a deductible, just ask for it at your doctor's office or take a prescription to a network pharmacy. Sounds simple and straightforward.

DH had a Doctor's appointment and asked for the shingles shot. They don't do them at the office, the doctor will send in a prescription, what's your local pharmacy?

DH gets home from the visit and gets a phone call from our mail order pharmacy. Your doctor sent a prescription for the shingles vaccine but we only do mail order medications. DH calls the doctor's office and tells them of the error, they resend, this time to a local CVS pharmacy.

DH goes to the local CVS and asks for the shingles vaccine. They take his insurance card but it comes back as not covered. They try again, it’s still denied.

DH comes home and I call the insurance company again . Yes, it’s covered, have the pharmacy process it as MEDICAL, not PHARMACY. Ok, that makes sense.

The next day DH goes back to the pharmacy and asks for the shingles shot, please be sure to process this as Medical, not Pharmacy. It’s still comes back as not covered. Would you like to pay $247.99? No thanks.

DH is quite perturbed by now. He’s retired and this is the most stress he’s had in a long time. It's already late Friday afternoon. We will deal with this next week. Ugh.

Before dinner we need to run an errand at the grocery store and while we are there I ask at their pharmacy, “Do you have the shingles vaccine and what’s the process to get it? We have been dealing with CVS and even though our insurance says it’s covered with no deductible CVS can’t get it to process correctly.” “Sure, let me see your insurance card.” We wait about 2 minutes and she comes back and says,”Yes, this is covered with no deductible, no copay, it just needs to be approved by our central office. I can send that in and call you when it’s processed, probably early next week.” DH says he can pick up a printed prescription from his doctor and bring it in and she says they don’t need that.

Wow, what a difference! So we went home and had dinner and soon after that the grocery store pharmacy calls and says it’s all approved and you may come in at your convenience, by the way, we are open until 9pm.

DH put some shoes on and went right up and got his shot, and a receipt showing no payment, no copay due. I have not seen this claim show up on the insurance site yet, so I will have my fingers crossed until I see it processed and paid in full.
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Old 11-30-2015, 07:25 PM   #28
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Just another data point:

I got my shingles vaccination this year (age 53 at the time) and it was covered by BCBS (Ohio, not Illinois).

Of course, it was administered at my PCP's office so I guess he approved it...
That seems to be the issue with OP's situation. The rule says prior approval. He didn't get prior approval. But I still think a formal appeal would be worthwhile.
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Old 11-30-2015, 07:32 PM   #29
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DH put some shoes on and went right up and got his shot, and a receipt showing no payment, no copay due. I have not seen this claim show up on the insurance site yet, so I will have my fingers crossed until I see it processed and paid in full.
Don't worry about the insurance at this stage. You have a receipt from the drug store saying "no payment, no copay due." You're done. If they bill you, forget the insurance company, just show them the receipt they issued. All done.

BTW, I chuckled over the earlier issues..... even your doc screwed up by sending the prescription to mail order.
I think I'm going to have mine done at the doc office if possible......
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Old 11-30-2015, 07:41 PM   #30
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Was does the insurance policy say about needing a PCP's referral or not? I think that is the key. Gone are to good old days I think where a BCBS card was the standard bearer.

I remember last year just signing up with them was such a headache. Trying to get a policy with them on the phone and the person getting stuck in the application saying computer problems, not sure why. I finally applied through ehealthinsurance.

This year, I'm going with a BCBS plan from the markeplace but my confidence isn't that high that they won't get confused in the process. Fingers crossed.
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Old 11-30-2015, 07:53 PM   #31
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That seems to be the issue with OP's situation. The rule says prior approval. He didn't get prior approval. But I still think a formal appeal would be worthwhile.
I think the saga in the OP's first post here implies prior approval in that several people in the insurance company told him it was covered and knowing his insurance status, still told him to get it at the pharmacy, not to get the PCP approval first. In that case I think the insurance company should cough up. And the conversations were probably recorded (I always get a recording before being connected to insurance companies that the call will be recorded "for quality assurance"), so BCBSIL can call up the recordings to verify.

Not pertinent, but I did get a shingles shot a few months ago (in doc office, insurance paid) and recently got a very mild case that lasted only a week.
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Old 11-30-2015, 08:23 PM   #32
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We had an insurance dispute (different issue) where calls and emails were all denied. Wrote a letter and a check arrived in our mail. I had shingles about 10 years ago and it was the most pain I had ever gone through. If you never get shingles the $217 is the the best decision you ever made.
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Old 12-01-2015, 05:50 AM   #33
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This year, I'm going with a BCBS plan from the markeplace but my confidence isn't that high that they won't get confused in the process. Fingers crossed.
Especially since in many states, they don't even offer PPOs any more -- only HMOs which require the PCP to be the gatekeeper to all other approved care and services.
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Old 12-01-2015, 06:15 AM   #34
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Especially since in many states, they don't even offer PPOs any more -- only HMOs which require the PCP to be the gatekeeper to all other approved care and services.
It's amazing that BCBS didn't tell ER50 up front that he had to go through his PCP first, if that's the most basic rule of an HMO.
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Old 12-01-2015, 06:19 AM   #35
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It's amazing that BCBS didn't tell ER50 up front that he had to go through his PCP first, if that's the most basic role of an HMO.
Yeah. It might not help in this case, but this is why, in the absence of recording a call, I at least note the date, time and name of the CSR on the other end of the line.
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Old 12-01-2015, 06:40 AM   #36
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Hmm...it sounds like he is blessed with a rather settled life in retirement. Then again, perhaps ours has been unusually stressful.

Good luck!

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DH is quite perturbed by now. He’s retired and this is the most stress he’s had in a long time..
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Old 12-01-2015, 07:11 AM   #37
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DH put some shoes on and went right up and got his shot, and a receipt showing no payment, no copay due.
I am so happy for the two of you! It sounds like the grocery store pharmacy took care of the problem when CVS either couldn't or wouldn't.

I can sure understand why this has been so stressful for your DH and probably for you, too. I think the most stress in my 6+ year retirement was due to a similar insurance/medical confusion several years ago (that is also now resolved). I think that for me, it would have been less stressful to be held up at gunpoint for the $350 that was in question.
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Old 12-01-2015, 10:02 AM   #38
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Yeah. It might not help in this case, but this is why, in the absence of recording a call, I at least note the date, time and name of the CSR on the other end of the line.
I did get the name and time date of each call, and for the second call, where she said it would be covered, I got a ref# for the call.

Of course, that was all ignored! I think they just have the equivalent of a "Chatty Kathy" doll, with only one recording "You are denied!".

But I will try the appeal process. First, I'm going to call my Doc's office, and see what they say. There's something about the actual billing goes through the HMO, so I don't know. All very confusing.

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It's amazing that BCBS didn't tell ER50 up front that he had to go through his PCP first, if that's the most basic rule of an HMO.

Right. I'm new to this, and my call was basically to find out if there were age or other restrictions. So when they told me to just go to Costco and it is 100% covered, I believed them!

-ERD50
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Old 12-01-2015, 10:04 AM   #39
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Sometimes I think that the folks who run the financial side of the medical industry are all lined up in front of the Congress and the White House, screaming in loud voices "Please regulate us! We need more rules, more standards and many more bureaucrats to tell us what to do and how to do it."

These boys and girls need to get their act together. They are their own worst enemy.
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Old 12-01-2015, 10:10 AM   #40
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Just for the record, not all states allow such a wide latitude. In some states both parties must consent in advance. This tripped me up once when I planned to record an in-person conversation. My attorney strongly advised against it based on the law of that state. Maybe phone calls are under a different law, but I doubt it.
Yeh the laws are VERY different in every state. That is why when you call into those places, they have to immediately state, the phone call will be recorded, if you don't wish for it to be recorded, blah blah blah. and if you are calling an insurance company you have no idea what state the person on the other end is actually in.
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