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!