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Monday, October 11, 2010

My Oxford Challenge

My son is going to do volunteer work in Africa for 6 months and was prescribed malerone to protect him against malaria.  He obtained the prescription, took it to the pharmacy AND...we were told it would cost nearly $2000, even though my health insurance policy carries an expensive prescription drug benefit.  Thus began my odessey with Oxford.
First Call: (32 minutes): Informed it was not a covered medication because it was for travel.  They agreed that there was no such provision in my policy but that was "Oxford's general policy".  Informed I could ask for an APPEAL OF COVERAGE, expedited with an answer in 48 hours.  Great.
Wrote appeal, sent to provided address with registered mail.
Second Call: (48 minutes): Requested response on appeal, informed after some time that in fact medication was covered and what I needed was a QUANTITY LIMIT OVERRIDE APPEAL since he had 6 months of pills ordered and was only entitled to one.  Again told an expedited appeal would be answered in 48 hours.
Faxed appeal as instructed.
Third Call: (32 minutes) Couldn't find my appeal, couldn't find anyone who could tell status of appeal, tried to get through to a medical department and was told they weren't answering their phones I could continue to hold or call back later...as I had to go back into the operating room, I concluded the call.
Fourth Call: (36 minutes) Got lovely woman who apologized profusely for all the calls and trouble but after invetigating informed me in fact malerone was NOT a covered medication! After I got a little angry, she put me on hold, and ultimately agreed I needed a QUANTITY LIMIT OVERRIDE APPEAL and gave me a different fax number and instructions how to use the facesheet to prompt a definite response.
Re-faxed appeal as instructed.
Fifth Call: (49 minutes) Kind man said the pharmacy stated I could only get 2 months worth-I tried to remain calm and ask why the appeal had been rejected and who could I speak with as the whole point of the appeal was to OVERRIDE this limit and I though as he would be far from a real pharmacy and even a reliable postal service I had good grounds to request this.  I was put on hold again and when he returned he apologized profusely and said I was misinformed...what I needed was as VACATION OVERRIDE APPEAL-this process means I have to purchase the medication out of pocket and then after I complete 5 pages of paperwork (without leaving out a single crucial item), Oxford will decide if I am entitled to reimbursement that they can send me at their leisure.

And we wonder if our health insurance system is broken?
Bon Voyage!


  1. Wow! Sure hope your son has a great trip.

  2. Bill Scharf (Cousin)February 1, 2011 at 4:35 PM

    I understand your anger. My wife and I have 4 college degrees between us, but struggle to grap the complexities of such annoyances. Recently my son got a Rx for wart cream because of a wart on his finger...the dr thought it was too close to a blood vessel to remove it on a preschooler. Luckily insurance covered it....but one box was about $1100. Per gram that was more than 4 times the price of pure gold!?! Of course the medicine did nothing and we were referred to a specialist....sigh....:-)

    Another thought for something like this...in a country where malaria is an issue, could you get some meds there? Of course not in the villages, but near the international airport? It is probably not worth the gamble....but just a thought.