Hi There,

Holy Cow, you are under so much stress. I absolutely hate Insurance companies.

I am on Medicare right now, so certain laws have been passed to avoid situations like yours, but here is what I do remember form my social worker days..

First, it is not going to be easy, but it can be done. Skip right over all those 20 people with no clue that you have been talking too, and ask to speak to someone that can help you file an appeal. Once you file an appeal the Insurance Company will have a limited number of days to make a determination (could be 15 or 30 days depending on what is in your contract.)

Here's the better news...Your appeal the decision that you must have your Infusion med shipped to the hospital or brought with you to the Hospital with you. You and your Immuno and any other Dr involved in your care can state that it is medically necessary for you to have your Infusions in a hospital setting (you have reactions, need to be monitored by an MD, site as many medical reasons as possible, and an Immuno should know all the big technical terms needed).

Since it is medically necessary that the infusions be given at the hospital, there is no way that the hospital can legally allow Caremark to ship your IVIG med to the hospital or for you to bring it with you (that is SO absurd) because the hospital is legally responsible for tracking the Lot and Batch numbers of all IVIG meds in their possession and are legally obligated by the FDA to report unusual side effects, serious side effects, or any pattern of side effects, and they can not do this if a single random batch # is thrown in the mix...it is just not safe, not legal, and the hospital can not track issues in accordance with FDA regulations with Stupid CareMark wanting you to "Brown Bag" it to the hospital. So ridiculous,

The "Brown Bag" Option is meant for patients who go to Infusion centers, not hospitals.

Besides being medically necessary to receive treatment in a hospital, the treatment itself is medically necessary, and Caremark is going to have a hell of a time refusing or denying your appeal.
The hospital can bill Caremark for the Infusion material, bill your insurance for hospital expenses, and what is not covered, will be billed to you via Caremark and your Insurance Company, and you can set up payment plans or join the millions of people in America who just cannot pay their medical bills, including myself.
Your other options for repayment are to ask the hospital if they have an indigent patient program (most do, but you have to ask) and you can ask Caremark if they offer financial aid.

Filing an appeal is exhausting, and I know you are already stressed, which does not help your health, but it does give you the best shot of getting your IVIG the way you feel is best for you, and every IVIG patient should have that right.

http://cvscaremarkspecialtyrx.com/patients/how-we-help/frequently-asked-questions

Toward the bottom of that page is Caremarks links and phone number on how to file a complaint, and then take it to the next level with their "Joint Commission" Nice words for Appeals Dept.

I feel so frustrated for you, I can't imagine how you feel...
I wish you all the best, and hope this all works in your favor
Best, LuLu

Hi There,
I am also a patient with CVID (on SubQ) and used to negotiate contracts for UnitedHealthcare. I was also their Contract Administrator. Now I'm disabled with Lupus, R.A. and CVID. I've also appealed things on occasion and have been fairly successful with my appeal ltrs. So, here's my take on the situation. So first, UHC holds a contract with CVS Procare. So, if UHC gives you authorization to have your infusion done at the hosp. UHC has the final say. UHC is the contractor. You don't have to listen to any one else's opinion. But, make sure that the approval is for more than one month and stipulates the amount of time the approval is for. Secondly, the hospital has to follow their own governmental & contract (with UHC) guidelines. So, I agree with LuLu''s's comments.

Are you speaking to UHC customer service? If so, ask to speak either to a Supervisor in customer service or a Nurse in Care Management at UHC.

Do you have someone at your doctor's office that is responsible for getting approval for your hospital infusions? Usually that person files an appeal with your doctor's statement saying that it is medically necessary for you to have your infusion at the hospital & that the hospital requires that the medications be supplied by the hospital. If there's not a person at the Dr.'s office to do an appeal, get a ltr from the Dr. and submit your own appeal.

Thirdly, ask to speak to someone in care management at UHC, ask that person to help you seek approval for your hospital infusions and medications. And if all of those measures fail, fax an appeal letter to the Medical Director at UHC stating the urgency of the issue (we are sick without our infusions). Good luck. I hope this helps.
-Juile

P.S. The wording in your plan summary matters. You just need to discuss the point that the other clause conflicts with your plan summary. Stay calm & positive, and ask to speak to someone higher up (then customer service) at UHC. Ask for help to solve the problem. And focus on your Dr's facts on medically necessity. Escalate the issue if necessary. Most people are willing to help you if you come with a sincere request for help.

JulAnendano,

Thank you so much for jumping in!

You have some really awesome insider information...
You are so right about staying calm and positive...I get worked up from my social work point of view, but frustration and anger won't get very far in an appeal. You do get much further with a calm and a We're in this together" sort of attitude.

I had also forgotten that there is usually someone at the hospital who coordinates your treatment, be it in hospital or home care...For me, there was a young woman in my Immunologists office who did everything and just gave me a time and date to show up.

It has also been my experience that you can appeal and get almost anything approved, with the write documentation and wording..Health care is big business, but the people in charge of appeals are still people...not the engineers of the money making machine health care has become, so most do want you to get the care you need, you just need to work with them and learn their language so to speak..

All the best, and welcome JulAvendano :)
Thanks for such practical advice :)

Thank you both! So far I've been working with a UHC supervisor and she's working with a patient advocate.

My medical benefits plan clearly states:
Therapeutic Treatments Home and Outpatient Covered Health Services will include charges by a Home Health Agency, home infusion company or infusion suite for the following services: intravenous gamma globulin
(I think this means my IVIG is covered under my medical benefits)

And my RX benefits clearly state:
Covered Charges will be the actual cost charged for the prescription, but only to the extent that the actual cost charged does not exceed the specific maximum scheduled amount allowed under the Payment Schedule.
Prescription Drug Covered Charges will include charges for:
the following injectable medications: Anti-Coagulants (Arixtra, Fragmin, Innohep, Lovenox), Epinephrine (Epipen and Epipen Jr.), Depo-Provera, Migraine Agents, and Glucose Elevating Agents (Glucagon); diabetic supplies: alcohol swabs, disposable blood/urine glucose/acetone testing agents, disposable insulin needles/syringes, insulin, lancets, Exubera, Exubera Chamber, Exubera Inhaler, and Exubera Release Kit for individuals 18 years of age and older; legend prenatal vitamins; legend oral contraceptives, including patches; compounded medications in which at least one ingredient is a Prescription Legend Drug; any other drug or medicine that can legally be dispensed only with a Physicians written prescription; and Self-Administered Specialty Drugs if dispensed at a Specialty Pharmacy. Specialty prescription drugs will need to be purchased through the Caremark Specialty Pharmacy and will be paid under Prescription Drug Coverage provided they are on the Caremark Specialty Drug List. If you need to determine if a specialty prescription drug will be covered under the medical plan contact Caremark at 877-494-9583.
Note: Patients with certain chronic or genetic illnesses may be able to receive specialized delivery of biotech drugs and related therapeutic services by calling CVS Caremark Specialty Pharmacy Services, CVS Caremark Connect, at 800-237-2767.

(I do not self administer my IVIG, so I don't think that my RX plan should/would cover my drug.)

However, UHC says that my employer selected a special plan that requires the following: (this information is found on their website - NOT on my benefits summary)
Specialty Pharmacy Program



Self- administered Diabetes products DO NOT fall into this category



All Specialty medications will need to go through Caremark's Specialty Pharmacy to be obtained. The only Specialty products that will continue to be covered under the medical plan are those that aren't on Caremark's Specialty Drug list and are ordered through a channel other than Caremark's Specialty Pharmacy. One example is oncology specialty drugs.

I can totally see how this is confusing (as many UHC reps even admitted to me that it was). How am I supposed to understand these contradictions when UHC can't agree amongst themselves. They certainly don't have the systems or procedures in place to support this wonderful new program they have.

So we'll see. We are going to file an appeal. LuLu - I totally agree with you about the maintaining proper controls for drug administration.

Jul - The soonest I could get an appointment to talk with a nurse on the phone at UHC was a week out, but they will be calling me.

Wish me luck. I'm blessed to have a great support system. My husband is going to help fight this battle.