Blue Cross not following the laws and denying pain management

Incredible news to share:
After my insurance decided to not cover my rx last week, they said that they needed a pre-authorization. I’ve been on the same rx and dose for eight years. Then, after my doctor filled out all the extra paperwork the following day, I was informed that they did not approve the pre-authorization. 😤

So. I got to work and started researching their policies and what laws they were basing them on.
I found a very specific law passed last year that implicitly states that I am a patient who is grandfathered into the plan and should not be held to new standards.
I got all of my information printed, hi-lighted, and ready for a fight. I called to speak with a specialist and supervisor.
I was getting the basic speech that is read off a script or training manual.
I kept my cool, then went in with all of the facts. I started quoting laws and policies, explaining how that affected me, and how we needed to fix the error and adhere to the state and federal laws, and bcbs policies.

They asked for this information again, as they were taken aback. I sent it to them, personally, in an email. I explained exactly what I expected and why I had a legal right to it. I quoted laws. I provided links to laws as well as to bcbs pages that applied those laws to new rules and policies. I explained that I was only one of many millions who are experiencing discrimination over this issue. I explained that we expect a change in our treatment and that we would prefer to settle these issues of abuse and discrimination outside of court, if possible.

Well. I got everything I asked for. Not only that, but they were so thankful for the information I sent. They’d never been taught about those laws and policies, or how they apply. And they certainly were not trained to counsel patients who call in crying because their medications are no longer covered, and they didn’t know until they showed up at the pharmacy to pick up their meds.
They said that out of the thousands (yes, thousands) of calls they’ve received at that call center in the past few weeks, I’m the only person who has ever presented any information like that.
They have since, in the last week, explained this information to all of their employees, printed it out, and now have a way to try and actually help patients who call. It’s implementation starts today!

I’m so excited for this!!!
Now, if getting the government to use their brains on this matter were as easy…..
But I have momentum now, and I’ve set a precedent. I will followup and follow through!


here is contact information for the poster of this information



19 Responses

  1. This is a job well done!! But if I know insurance companies they will go right back to denying and marginalizing the next patient. I think it would be really helpful if the author could provide the specifics in terms of the persuasive information that she uncovered and supplied so that other patients can follow in her example and hopefully have similar success. CHEERS!

  2. Congratulations. That was a lot of work, but so worth the result. Thankfully my prior auth. was accepted and I’m good until next July.

  3. burn every pharmacy and fed,bldg,to the ashes.If any of them gets burned,tell em “Welcome to our club!”This all has me on a vomiting regimen

  4. Nice job! Thank you!!

  5. It pays to keep up with changes in federal and stare laws. As well as with policy changes with insurance.

    In 2007 a doctor I had told me state laws had,recently changed. He could no longer give me refills on Lortab10. I told him I followed the recent legislative session In our state. No laws had been passed preventing refills on Lortab or any other prescription drugs. He told me I was,the only one of his patients that knew there had been no changes. He gave me refills. I overheard other patients talking at my next appointments. I was,the only patient receiving refills.

  6. I hope it worked with Blue Cross. It sure didn’t work when I tried it on my pain clinic Dr.. Showed him laws grandfathering me in, he didn’t care. Was at 350 MED’s for pain by my world class rheumatologist when he was threatened by the DEA for prescribing high doses. I got high doses not only for many painful medical problems but I have trouble absorbing nutrients & medicine because of a gastric bypass for pyloric valve stenosis. Forced him to drop his chronic patients & forced me to go to this pain clinic. They told me it would take 12-18 months to cut me back safely to the clinic level of 90 med’s/day. They cut me back to 60 in 6 months. Also cut my muscle spasm medicine in half creating a host of new problems. He then informed me that he didn’t believe in opioids and was taking me off all of my medicine. I attended the Aug. 22 meeting of the state rules commission (WSMA) and told them. They were shocked and said “Nothing’s changed for chronic pain patients. You should make a formal complaint,” I said “You should educate the doctors because they are all doing it.” I went to a new pain clinic and the doctor is taking me off Oxycontin completely (“Oxycontin is Bad!”) He’ll leave me with 20 med’s a day of Oxycodone and won’t answer about increasing the muscle spasm medicine. Quite a comedown from 350 to 20! So, if the state rules committee can’t fix the problems with the doctors, I guess we’ll just have to keep on having rallies until they believe us that we won’t stand for this stupidity. Prohibition didn’t work last time and it won’t this time either for the same reasons. However, the consequences are hurting a lot more people, so KEEP FIGHTING FOR CHANGE!!

  7. As the above comment asked , please post the information you’ve found and used so the rest of us dealing with this issue can also benefit from it. I was recently brought down on my meds again because they kept refusing my prior auth. I have Caremark and suddenly they’re go8nf by the cdc guidelines. I’m suffering terribly so I’d be greatful for the info to see if it helps !!!

    • I also had Cvs Caremark and they keep denying my hubby pain med that he had been on same dose for 8yrs.I finally called his employer and told them what was going on and I wanted to appeal thru them .I told them i was going to report to state medical board that all I evolved were practicing medicine without a license. I told them all we have to prove is medical nessecity and the guidelines are not condoning force taper for stable patients. Employer gave me 1 person to talk to anytime I have problems and they are now paying for original dose every guess is employer didn’t want to deal with us i also said i belong to many advocate groups and media were I interested in how this company is treating their employees with rare incurable painful diseases.

  8. Awesome I had the same issue and ended up paying cash.

  9. I tried that with my pain clinic doctor when I was forced to leave my world class rheumatologist. Tried showing him paperwork that I was grandfathered in. He didn’t care. I was at 350 med’s for my pain (also because of a gastric bypass for pyloric valve stenosis my body doesn’t absorb nutrients or pain medicine very well. They told me they were cutting me back to the clinic level of 90 med’s; would take 12-18 months They cut me back to 60 in 6 months! The doctor then informed me that he didn’t believe in pain medicine and they were going to take me off everything including my muscle spasm medicine (they’ve cut that in half). I went to a meeting of the pain rules committee in WA (WSMA) to find out why he’s getting away with not treating pain w/opioids. They were shocked and said “Nothing’s changed for chronic pain patients.” I said “Where have you been, it’s that way everywhere!” They suggested I make a formal complaint against the doctor. I suggested they make an effort to educate the doctors about the rules. I moved to another pain clinic w/hope I could get my pain med increased at least to the CDC level. Instead, I was informed that “No way would I ever do that!” He’s taking away my Oxycontin (said it’s bad!!!) leaving me w/Oxycodone-20 med’s/day. Quite a comedown from 350. Won’t talk about the muscle spasm medicine! Guess the only way to change thing are these pain rallies. Repeat them until the gov’t understands we won’t stand for this! Prohibition didn’t work the first time and it won’t work this time either for the same reasons. “People who don’t learn from history are doomed to repeat it”.
    Hang in there & keep fighting!

    • What happened to you is beyond appalling.
      I find it interesting –in a hideous sort of way– that the language of medicine is changing to the language of religion, i.e. “I don’t believe in opioids.” They’re not like gods or fairies or ghosts….”belief” should not be part of the dialogue. Is there evidence to support their efficacy and safety for chronic pain patients? Despite what the hysterics constantly scream, yes there is. Is there evidence to show that ripping away a person’s medication –that they’ve benefited from for years without adverse effects– is dangerous? Yes, though there needs to be more. But since this nationwide experiment upon CPPs is being performed with no controls & no follow up, it’s not likely to show up soon.

      The goal of these idiots is to decrease opioids, period: what that does to patients or the “opioid epidemic” or anything else is completely irrelevant to them. They want to decrease because they want to decrease because they “believe” in decreasing, and decreasing is, ipso facto, good. It’s perfectly and hellishly circular.

  10. Nice job.
    Did you record?
    Got anything in writing?

  11. Will you share those laws with us soon. Thanks and great job !!

  12. Well you caught them. I have a very hard time the lawyers and higher up did not know these laws they were just hope you would be the typical patient and just give up. Most of these companies who deny your meds is some flunky who has little or no medical training just looking for certain words or codes. If you doctor does not know those then you do not get your medication. Basically you have the right to know the name of the person who deny your medication and what is there background training and experience. Many time the people who are making the final decision have no chronic pain training or ever worked with Chronic pain or anything else. Many time you have to fight to get this person name because they do not want to you to know the person is not qualified in anyway to make the decision. When you think about it is all about money just like every darnj thing in this country

    • You are 100% correct!! I worked for An insurance company many years ago right out of high school . 20 yrs old paying medical claims, no college, just training in paying clains, entering codes into system, its all set to pay or deny, the ones denied would go to appeal process which went to our supervisor. We did have a nurse case manager that approved or denied the higher amount claims, as each claim processor was allowed to pay up to a certain dollar amount, then it went to those above us. I never even seen the case manager to be honest. And now with all these forever changing opiod laws further restricting the chronically ill from thier lifesaving pain medication but if you admit your an addict youll get all the help u need, including brainwashing you to believe that the pain was in ur head, as your body rages hell on you. Our Government and company is killing us off. and not one big time tv outlet cares, maybe we need to make commercials like the animal abuse ones, those seem to reach out to the hearts of all, mayb someone will have some compassion for the suffering.

  13. YAY!!! Now I’ve got a little hope back…, thank you

  14. wow…evidence that actual facts can still matter occasionally! Helps me keep slogging along in the fight against The Oregon Insanity, where facts have become fog.

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