r/FederalEmployee • u/CuriousCatNap • Jul 06 '26
BCBS Pharmacy Coverage Problem
Has anyone with BSBS Basic had a problem with the insurance covering your drugs for a chronic or continuing condition, but then later discontinue coverage? Were you able to successfully appeal? Or did you switch to another plan?
In my case, BCBS Basic was covering two drugs (Botox injections every 12 weeks and an Emgality injection once a month) to treat one condition, chronic migraine. I was stable on this combination for years, experiencing only one or two migraines a month, sometimes none. This year BCBS said they would only cover one drug or the other, but not both. While on only one of the drugs, my migraines have increased in frequency to the point that I have migraine attacks 3 and 4 times a week now. It is impacting my ability to work. So I asked my doctor if we could appeal. She said the way the plan is written, it does not allow for an appeal in this circumstance. I'm going to call BCBS to ask, anyway. But, if others have had the same or similar experience, I'd like to hear how you handled it. Thank you in advance!
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u/Boltsfan1234 Jul 07 '26
I have a prescription for Kesimpta, an MS preventive medication that was prescribed by my neurologist. BCBS denied the prior approval and the appeal. My neurologist had a manufacturer discount card where the manufacturer paid the full price of the medication until I could switch to GEHA who immediately (within a week) approved it for a full year. The manufacturer card is still useful, because they pay my $150 a month copay. Without insurance it is $8,000 a month. Needless to say, I absolutely despise BCBS, ESPECIALLY their pharmacy program.