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Insurance Carrier: Blue Cross Blue Shield of New Jersey
State: Missouri

Consumer Complaint:

BlueCross BlueShield representing American Water Works Co. has not approved a covered Medicine. My Doctor sent a letter of need, that they received, in the middle of January 09. BCBS said it would take 8 weeks to "approve". Why so long to approve? It is a covered benefit! I need the medicine to prevent further damage to my body, and to stop a medicine causing a lot of side effects and other health problems. I did not renew my old prescription because it was a 3 month supply and I had to quit taking it a month before the new medicine. The medicine stops further damage. BCBS is causing me to get worse and my body is getting damaged daily because of their incompetence and greed. They don't want to pay for the medicine. I need help. Missouri cannot help due to an out of state insurance co. The other problem is the American Water Co. claims to be self insured.

Insurance Expert Answer:

One problem is that the costs of some newly developed medicines seem outrageously high and they often are generally not more effective than older, far lower cost drugs.

Other costly drugs are often prescribed by doctors even though they are not approved by the FDA for a specific condition; they are being used "off label" for that condition on an experimental basis.

Some plans require you to go through a sequence of steps before you use a specific drug as opposed to a generic. And doctors very often do not take costs into account when prescribing drugs.

If the drug is listed on the plan's formulary, and it is approved by the FDA for your condition and prescribed by the physician, they should pay for it. If it is not FDA-approved, or not on formulary, the plan didn't agree to pay for it and need not pay for it.

If the plan is self-insured, the Blues are acting as an administrator and doing the plan sponsor's (here your employer) bidding as they are instructed to do.