Insurer Bumbles Question About Drug Coverage
Seattle Times Staff Columnist
Get it all in writing!
That's the best advice I can give a consumer whether it's Victoria Doyle, a heart-transplant survivor, who has been in a complicated dispute with an insurance carrier over drug coverage, or someone who can't get a widget they ordered.
Ten days ago, it appeared that Doyle's dilemma was resolved. Based on a letter Regence BlueShield sent to Don Sloma, a deputy in the state Insurance Commissioner's Office, I wrote that the carrier had decided the transplant benefits in Doyle's policy would cover medications she needs to survive - immuno-suppressants and drugs to control cholesterol, blood-pressure and stomach acid.
But just three days later, Regence reversed itself, saying it had approved only the immuno-suppressants Doyle requires, under her $200,000 lifetime transplant benefit. The other medications would be charged against her prescription coverage, which is capped at $500 a year, leaving Doyle to pay $4,300 a year out of pocket.
Regence spokesman Chris Bruzzo explained that the health plan's pharmacists ruled the other drugs were not related to the heart transplant.
But Doyle says her physicians contend all these medications are required because of the transplant. And, she adds, she did not have high blood pressure or cholesterol, or stomach-acid problems before the transplant.
Bruzzo said the first letter to Sloma, signed by Waltraut Lehmann, Regence's manager of regulatory affairs, dealt only with the immuno-suppressant drugs. The other medications were reviewed separately.
"We were not aware of the other drugs that she felt ought to be applied (to the transplant benefit) and we should have taken a broader view of all her medications," Bruzzo said.
"The positive thing is we did review it and we have approved all seven drugs. And we are apologizing to Doyle for the challenges."
Lehmann's initial letter did not single out the blood-pressure, cholesterol or stomach-acid drugs for added review.
It said, in part:
"We did not recognize that her drugs should be counted against her transplant benefit, instead of her retail-drug benefit. Consequently - we are sorry to say - she was informed that, when she reached the $500 limit on her retail-drug benefit, her medication would no longer be covered." The letter mentioned a billing problem, but said it would be corrected. There was no hint that the review of coverage would continue and that a different outcome was possible.
"We took that (Lehmann's first letter) to mean an `all clear signal,' " said Jim Stevenson, a spokesman for Insurance Commissioner Deborah Senn.
Lehmann's second letter to the insurance commissioner's staff said Regence's decision was final: the added medications were not transplant-related. Lehmann said she understood Doyle would appeal.
Doyle said when she asked Regence and the insurance commissioner to review her coverage, she asked about all the transplant-related medications, not just the immuno-suppressants. But Doyle acknowledges that she made that request over the phone, not in writing.
Frankly it doesn't make much sense to me to tell a consumer they are covered one day, then inform them a few days later that they are only partly covered.
It's also odd that Regence has been paying for all of the medications since Doyle bought the policy in November 1996. Doyle says she always has purchased the medications through the pharmacy at the University of Washington Medical Center, where she had the transplant in 1991.
No one could explain the change of heart to me.
When Regence seemed to be reneging on its promised coverage last week, the insurance commissioner's office re-opened its probe.
I made some more phone calls. Among other things, I asked Regence for a letter that specifies what drugs it will charge to Doyle's transplant benefits.
Doyle says if she has future questions about coverage, or gets phone calls she will ask for everything in writing.
Doyle's dilemma is one more reason to support the insurance commissioner's proposed rules for more drug-coverage disclosures by insurance carriers - before consumers sign up for health plans.
Shelby Gilje's Troubleshooter column appears Wednesday and Sunday in the Scene section of The Times.
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