Well, if anything needs to be thrown onto the trash heap, this is it. Last year, I decided to have my teen & tween vaccinated against cervical cancer. You have seen the commercials for Gardasil--"one less" campaigns that run frequently on television. I did some research and soul searching, and decided that it would be of benefit to them to get vaccinated. I checked with our insurance company to see if it is covered. We happen to have prescription coverage with MedcoHealth and the rest of our insurance is through Blue Cross Blue Shield. Anyway, I checked coverage with Medco and discovered that they do not cover the vaccination. Blue Cross Blue Shield covered it though. We started the series of three shots to be given at very specific intervals. We had the first one done--no problem. We then moved to another state at about the time the second round was due. I had to scramble to find a place to get the second shot. Not being established with a doctor yet, I chose to take the girls to a Nurse Practitioner who could get them in. The second round was done--no problem. Along comes the time for shot number three. In the meantime, I had found a doctor who could take the girls as patients and got them established there. This particular doctor doesn't have a large number of young patients, so she doesn't keep the Gardasil vaccine on hand, rather, when it is needed, she writes a script and the patient goes to fill it at the pharmacy and brings it to the office and a nurse injects it. Okay, that's the way it is when you live in a rural area, I guess. I did that and, as I knew, the MedcoHealth insurance would not pay for it--it is not covered. I had no choice but to shell out the $365.98 for the vaccine out of my pocket. I took the girls to the doctor's office, and the nurse injected the stuff, but of course could not bill Blue Cross Blue Shield for anything other than the office visit.
To make a long story short, I am stuck with a $365.98 bill because I filled the prescription. After talking to representatives from both MedcoHealth and Blue Cross Blue Shield, I will now have to appeal to the people at MedcoHealth to pay for it. MedcoHealth, by the way, is one of only two insurance companies that I have heard of that doesn't cover the Gardasil vaccine. Maybe this will catch them up to the 21st century and get them current on what is happening with patients these days. At this point, each of our insurance companies is pointing their finger at the other as to who should pay. So far, I'm the only one who has put out any money.
2 comments:
MEDCO covers Gardasil just not for Epire HMO plans. Medco Medicare Prior Authorization Plan apparently has an age restriction for Gadasil coverage (here's a link.) Empire HMO never established an age restriction with MEDCO, although they have one clearly stated in their January 2007 newsletter (link). Like you, I had the same problem getting a straight answer from both companies. However, there's an appeal process you can start through MEDCO, then through Empire BCBS, and then through the company paying BCBS to provide you this "coverage". What I found out is, MEDCO follows the plans BCBS sets up and authorizes for them...Empire BCBS said they will cover the vaccine for women age 9 to 26, so their plan should translate into MEDCO coverage on the same terms. Unfortunately, the plan at MEDCO says there's no coverage, which means BCBS never notified MEDCO about their conditions about Gardasil coverage. If you start the appeal process, you can start clarifying with MEDCO and Empire BCBC whether EVERY woman between ages 9 and 26 and covered by Empire HMO (or whatever your plan is) pays the full price for the vaccine, like you did, while BCBS says that the vaccine is covered for that age. This is the basis for writing these appeal letters. Good Luck.
Thanks for the info. I never updated this post. I went through the appeals process and they still denied my request. The hang up was that I had to go to the pharmacy and get the vial of vaccine for my girls. It wasn't right there at the doctor's office. That little extra step cost me over $300.00. Later in the year that doctor told me she had started carrying the vaccine in her office so that wouldn't happen to anyone else. Gee, thanks, doc, glad I could be of some use! Chalk it up to experience, I guess.
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