Pondering the Key to the Universe of Blue Shield

I had nothing to write about today -- or yesterday, for that matter -- until I went online to register my new membership in that most august health insurance entity Blue Shield. I found myself not in a dark wood but rather on a well-lit path with easy markers. I clicked here and traveled there and landed on my home page with the names of my three children below my own. I clicked on each child's name and was denied access. I was told to give my children's email addresses to the Great Oz so that said children could approve my access.

Apparently, the well-lit path led to a fortress.

What is this strange order? I thought and in lieu of giving out my children's emails to a Corporate Entity, I decided to call and speak to a Representative.

I made my way, again, through the labyrinth, this one accompanied by piano music and Hall and Oates. The Representative came on the line, and when I asked him why I had no access to my minor children's medical information, he told me they were obliged to protect everyone because of Hippo Laws. I know about the HIPPO laws, I told him, but I've never heard of asking for children's emails to get permission for their parents to access their medical records. This seemed to stump the Representative enough that he was exceptionally gracious when I asked him what to do, what to do about my Adult Child Who Doesn't Talk. I have appropriate conservator/guardianship papers, authorizing me to access all her information, I told The Representative. I really need to do that quickly as I have some work laid out by your august company to get Sophie's drugs pre-authorized since they are not on your formulary and your people need to know whether they are indeed medically necessary or just a little something that we're taking for the hell of it. (I actually didn't say that last part). The Representative said that he could help me out with that and then he sent over the internets an Important Form for me to fill out and then fax. I then asked him whether he could help me with the Pharmacy Task, and he said that he could not but that he could transfer me over to The Pharmacy Keeper. I clutched my key and went on hold. I stayed on hold, listened to the piano music and Hall and Oates, and then I was turned away, disconnected. Disconsolate.

I went to my email to download the Important Form that would Authorize My Representation of My Disabled Adult Daughter, and here's a screen shot of what The Representative sent me:

Help me, Rhonda.

The Greatest Healthcare System on Earth, Part 5,346,789,340

a scene from Brazil, the 1985 Terry Gilliam flick whose brilliant scenes prefigured my life by 3 decades

I opened an Explanation of Benefits online this afternoon and noticed that the cost of the bloodwork (ordered by Sophie's doctor to check whether or not she had an anemia  or something worse problem) was not covered by Assurant, our new insurer. I had specifically looked up and found an In Network Lab, which, according to my insurance company acumen, means there would be no charge.  On the Explanation of Benefits page, under the Remarks column, were the numbers

1001, *0204

I followed the little asterisks down the screen to the explanation for these groupings and read:

0204: This service/equipment/drug is not covered under the patient's current benefit plan.
1001: This type of service is not covered under the plan. Please refer to the certificate.

Oy vey, ya'll. You know what that means, right?

I called Assurance, was put on hold and then finally spoke at length to one of their people. She was patient -- I'd say robotically so -- and kept putting me on hold to research your problem. She came back to say that there were several problems involving erroneous coding from The Provider that neccessitate my calling The Provider, asking her to change the coding on the original prescription, then calling the lab to authorize said changes, then have the lab issue a corrected claim to the insurance company, and then for me to mainline some heroin. 

The Assurant agent also told me this:

We do not cover venipuncture.

I said, But you do cover bloodwork?

The Assurant Agent said, Yes, but we do not cover the venipuncture service.

In other words, I pay private insurance so that Sophie's blood may be analyzed in a lab for possible horrible diseases, but that private insurance will not pay for the means to remove the blood.

Help me Rhonda.

What I look like when I'm on hold with Anthem Blue Cross, part 45,234,965

Ya'll, the tentacles of the great and almighty Anthem Blue Cross are still wrapped around me. As some of you know, our relationship is rocky at best, a desolate wasteland, at worst. I have been trying to extricate Sophie from the grasp of the beast for nearly two months -- via telephone, regular mail and then certified mail. I resorted to calling that other beast -- The Bank -- to cancel automatic payments to Anthem. Still, the bills came and today's even had $50 of interest tacked on to the warning that coverage would be terminated after interest and premiums were paid.

What the hey?

The Anthem Computer Man led me through the labyrinthine halls and into a windowless room where I was told that my wait time would be twenty minutes and the sweet, sweet strains of Bach played. I started typing. An Anthem Human Man came on, lo and behold, after twelve minutes and spoke gently. I don't see any letter stating cancellation, he said. Of course you don't, I said good-humoredly. The Anthem Human Man made some gentle entreaty about HIPPO laws (and yes, I know they're not really hippo laws) and I explained that my daughter, the said Sophie, the MEMBER, was my severely disabled daughter and that I spoke for her as she couldn't speak. At all? the Anthem Man asked. That's right, I answered. You'll notice that all communication regarding her account has my name on it as well, I added.  He went to check the hippo pond, gentle strains of Bach came through the speaker, I tapped my red fingers, wondered how deep the mud was in the Anthem hippo pond and contemplated the universe.

The Anthem Computer Man is taking care of things right this very moment, as I type. Bach is still playing.

Thank you for your patience, he whispered in his reed-thin voice, and I slithered out from under his arm, the last sucker -- pop.

Big, Long F**ing Sigh (and a bit of a rant)

from Anthem Blue Cross, dated 17-Jan-2013:

Dear SOPHIE,


We would like to follow up regarding the grievance referenced below. We appreciate your taking the time to express your concerns to us, since it is through such communication that we are able to continually improve the quality of service that is provided to our customers. 

Please be assured that the issues you have brought to our attention have been reviewed and appropriately addressed.

Anthem Blue Cross (Anthem) received a grievance regarding the non-formulary status of the prescription drug Onfi. The grievance requests that we add the drug to the formulary, since it is a very expensive medication. You are now forced to go to Canada to purchase it at a reasonable price, and your doctor has included a letter of necessity.

I can understand your frustration with the classification of your prescription. Unfortunately, Anthem is unable to alter the terms of the plan for any one member. If you wish to take a medication that is non-formulary, you are certainly permitted to purchase this drug.

...

The Onfi prescription is expensive and there may be only a limited number of members who use this drug. Anthem regrets that at this time it will continue to be considered non-formulary. 

...

[Blah, blah, blah]

Sincerely,

BRENDA H. SKALA
G&A Representative
Grievance and Appeals Department

Well, I guess my next step is to request that the drug be "reviewed for formulary consideration at the next quarterly meeting." I'd love to call up Ms. Skala and give her a piece of my mind, but why bother? She's probably not even a real person.

I've beaten the dead horse on this one, folks, over and over. Who the hell are these people? Why, why, why don't we have universal health coverage? Why does an insurance behemoth constantly come between us and our doctors? Why are the obscene profit margins of insurance companies not more roundly denounced? Why does a drug cost Sophie $63 a month in Canada and $990 in the United States? The same drug? Why? Could there possibly be millions of children in Canada who are on the drug and thereby the price is lowered due to demand? Why is Sophie not entitled to a medication that helps her at a reasonable price? Why do people object to entitlement when it benefits a seventeen year old disabled young woman who has grand mal seizures twice a day every single day of her life? Why?

Calling on the Posse, Part II

Just in case you've stumbled upon this blog as the result of searching for "big guns," "women with guns," "right to bear arms," or some other such bullhonky, this post is actually another rant of a crazed politically liberal woman with an independent health insurance policy and a child with exceptional healthcare needs who is waiting in fear for the envelope from Anthem Blue Cross that will inform her that her monthly premium will be rising by some outrageous amount in February of 2013. If you were, in fact, hoping for a photo of a woman with a gun or were just shopping around the internets looking for confirmation of your insane need to protect your gun rights now that the country has elected -- for the second time -- a half-black socialist who is intent on taking over the country you love -- well, you've come to the wrong place. Because this blog is actually about the ridiculous fear that many of us who own Anthem Blue Cross insurance policies have about the upcoming proposed rate increases. It's also about the confusing parts of The Affordable Care Act and insurance exchanges and what they might mean to us and when they kick in and what more do we have to do and how do we do it? This post is also about the chat I had over the counter with the nice pharmacist at The Rite-Aid yesterday about whether or not Anthem has added clobazam, the drug that actually helps Sophie, to its formulary so that it will cost $30.00 instead of $400.00 or whether I should just make my plans to fly up to Vancouver in a couple of months to purchase the drug for $63.00 because evidently the pharmaceutical company is jacking up the price here in the United States but not in Canada. The pharmacist confirmed that I will be flying to Vancouver. This post is also meant to provoke my Readers' insurance questions, all of which I'm going to compile into some sort of document and then try to find the answers to them, collectively (not socialist, but collectively).

So, Reader, do you have any questions about your insurance coverage and/or what you might expect as we move forward with the lumbering Affordable Care Act? Feel free to rant a bit about the fact that we don't have universal health care coverage in this country, and if you live in one of the many states that are refusing to enact health care exchanges or implement the ACA, leave a rant here, too. And if you're one of those people who thinks we're all lazy bums for wanting universal healthcare coverage, you can just keep googling "big guns," and "right to bear arms" and click right on off this page.

We have our own posse, and it's growing.

This has nothing to do with Christmas

so it's a break in that sense. And it's been quite some time since I posted an I Smell Bullshit rant. Lots of sarcasm, here, and bitter, coping irritation.

Yesterday, I took Sophie to The Neurologist to discuss The State of Sophie, Inc. We went over various medication options over tea and cookies (only one medication left to try) and Sophie demonstrated one of her larger seizures, spontaneously, for The Neurologist's edification. We left with a prescription for locosamide or Vimpat, the prettier name, wished the good doctor Happy Holidays and went on our way.

Today, I took the prescription over to The Pharmacy and several hours later received a call from The Pharmacist.

Hello! We spoke with your insurance company regarding the Vimpat, and that drug is not covered on your plan. However, they suggested you replace it with Lamictal, which they will cover.


With my mouth hanging open (Lamictal? Now the insurance company is replacing anti-epileptic drug suggestions from my doctor?), I told The Pharmacist that no, we can't just take Lamictal, a drug that Sophie was on over five years ago for about seven years and that I guess I would call the insurance company and see what was up. The Pharmacist told me that he would order the drug anyway, that it cost $367 for the three week supply and that he hoped we could straighten it all out.

Here's the Christmas part of this post:

Ho!!! Ho!!! Ho!!!

I made the call to The Insurance Company (Anthem Blue Cross) and spoke briefly to an enthusiastic clerk who advised me to have The Neurologist call The Insurance Company for an authorization for medical necessity for the Pharmacist for Vimpat for Sophie. Then he wished me Happy Holidays and is there anything else I can help you with?

Ho!!! Ho!!! Ho!!!