Complaint / Review
Blue Cross Of California
Removed expensive med, no available substitute, generic, from formulary, then lied saying it was never on formulary, now can't afford! Ripoff

I am self-employed and have had Blue Cross of California's Individual PPO Share 2,500 plan for about 6 years. Up to now, I haven't experienced any major problems, although copayments for certain medical tests are rather steep.

I was diagnosed with narcolepsy/cataplexy 2 years ago, and as a result I take 2 medications regularly to control the condition. Cataplexy is the same muscle paralysis that everyone experiences when they're in REM sleep so they don't act out their dreams. But some of us narcolepsy sufferers experience this while awake, which can result in falls, broken bones, etc.

My doctor prescribed a new drug that was developed to treat cataplexy, the first one ever. It was like a miracle, and has changed my life! Blue Cross said it was on their formulary, so I would pay the usual copay of $30/month for it. I was thrilled!

Well, after a couple of months, they decided to take it off of the fomulary. I suddenly received an astronomical bill for that month's supply. When I called Wellpoint, their pharmacy benefits provider, they informed me that indeed the drug was removed from the formulary. I asked how this could be, since there was no generic and no substitute drug available, and they couldn't answer the question.

My doctor was appalled and says they had no right to do that. I filed a grievance with Blue Cross, and their response was that it was never on the formulary! They lied, and said that I shouldn't expect to pay a small copayment for a nonformulary drug. I followed through with a complaint to the California State Department of Managed Health Care. Upon completing their investigation, they sided with Blue Cross, apparently believing their lie that it was never on the fomulary.

I am in the process of filing yet another grievance, this time including the proof that I was paying the formulary copayment for this drug (well, twice because that lasted all of two months), but in the meantime I don't think I'll be able to afford to continue the drug. What liars they are! And every year, my monthly premium goes up about $94.