Blue Cross Blue Shield Federal employee Program
I also have BCBS Fed Employee and there are a few more things that you will need. From what I understand, I am also just starting, you need to have 6 months of medically supervised dieting first. I have also learned at my 1st appt with my pcp that ins will not pay for a weight management appointment, so you need to find another doc to see for those appts or see what the out of pocket costs for an appointment with the pcp. I have not researched this as of yet. What state are you in? I am in FL and there may be some differences.
Katie
on 7/12/08 1:08 am, edited 7/12/08 1:09 am - ypsilanti, MI
I have FED blue Cross also and I am also starting this journey. I have called the insurence company and all they have told me is that I dont need pre authorization. In the insurence book all it says is.... you have to have a BMI or 40 or more OR a BMI of 35 with two comorbitities who have failed CONSERVATIVE measures to loose weight. No where in the book does it say I have to have 6 months of medicaly supervised weight lose. However the bairix clinic and my PCP tell me that I do. So now I am very confused, Who's right?
What I do know is, Iv have tried everything I mean everything except go to my PCP for weightloss drugs. BTW my PCP prescribed me Fastin yesterday and Im not to happy about that drug. However I have a great PCP who told me that we will do this 6 month thing but we have to make sure that I DONT LOOSE ALOT OF WEIGHT so my insurence wont deny me. He gave me a wink and a smile. And he supports my desicion completly.
I think I am going to call the inurance company again on monday and demand to speak to somebody who knows what they are talking about and if I dont get answeres there, I am going to call OPM or our employee help line through megellan.
I will let you know what I find out on monday.
I also have BCBS Federal Employee Plan (Basic). I am starting the process myself. This is what the insurance company AND the hospital that I plan to have WLS at tell me: You have to have a BMI of 40 or higher or a BMI of 35-40 with co-morbidities to be eligible. I was also told by my insurance company that they no longer require a person to be treated by a dietician/physicial for proof of 6 month weight loss attempt.
If you meet the BMI qualifications (either one), then a psych eval is required (which is covered by ins). Then the surgeon may or may not require a sleep apnea test (if you have this test done, the ins. also covers this.
My insurance company quoted me (just yesterday) that my only out of pocket expenses will be $100 per surgeon (which there is only usually one) and $100 per night you stay in the hospital (which my hospital only requires one night stay for lap. gastic bypass)....
From what I have been told, our insurance company is less stringent amongst all other others out there regarding coverage for WLS. So, I'm happy to hear about this. But I'm still holding my brea****il I get approved. Waiting is the terrible part.
DeEtte
Hi There!
I used to work with insurance and I think most of the BCBS companies generally ask for the same things as follows:
6 consecutive months of clinically supervised dieting
Nutrtionist or Dietician consult both pre op and post op
Mental Evaluation
40 or more BMI (or 35-39 with a comorbity)
a letter from your physician referring you to the surgeon
Prior Authorization is required usually for ALL BCBS companies
You can always call your insurance company again. Write down the name of who you talked to and when you talked to them. Just stay calm and be persistant with them. They CANNOT refuse to give you information. Just ask them what ALL of the requirements are for Bariatric surgery and also MAKE SURE you ask if your particular surgeon is covered and the hospital/clinic you will be staying at.
GOOD LUCK AND LET ME KNOW IF YOU NEED ANY MORE HELP :)
on 7/14/08 6:09 am - ypsilanti, MI
OK so here’s the outcome from today. I called the Barix clinic who told me that THEY pre authorize before sending to the insurance company and that with their experience the 6 months consecutive professionally monitored diet was a requirement for our insurance. I argued with her over it, because it doesn’t say anything in the benefits guide about a diet. So she called the insurance company and they explained that YES it is required and it is in the book "which says conservative measures to loose weight". So anything like weigh****chers, jenny creig or through your PCP is sufficient. However, I’m a little upset....Iv never done weigh****chers or jenny creig for financial reasons. And I have never gone to my PCP for pills. The only time a seen a PCP for weight was long before the four year requirement mark. But I have done Bally's and Curves and a thousand diets before, none of which qualify. So I guess I’m stuck waiting for six months.
OK so here’s the outcome from today. I called the Barix clinic who told me that THEY pre authorize before sending to the insurance company and that with their experience the 6 months consecutive professionally monitored diet was a requirement for our insurance. I argued with her over it, because it doesn’t say anything in the benefits guide about a diet. So she called the insurance company and they explained that YES it is required and it is in the book "which says conservative measures to loose weight". So anything like weigh****chers, jenny creig or through your PC****ufficient. However, I’m a little upset....Iv never done weigh****chers or jenny creig for financial reasons. And I have never gone to my PCP for pills. The only time a seen a PCP for weight was long before the four year requirement mark. But I have done Bally's and Curves and a thousand diets before, none of which qualify. So I guess I’m stuck waiting for six months.
Gastric restrictive procedures, gastric malabsorptive
procedures, and combination restrictive and
malabsorptive procedures to treat morbid obesity –
a condition in which an individual has a Body Mass
Index (BMI) of 40 or more, or an individual with a
BMI of 35 or more with co-morbidities who has
failed conservative treatment; eligible members
must be age 18 or over. Benefits are also available
for diagnostic studies and a psychological
examination performed prior to the procedure to
determine if the patient is a candidate for the
procedure.
No where does it mention the length of time for failed conservative treatment. Nor does it mention a four year requirement mark. Because if that's the case then I am in the same place with you. If they do not approve me I will appeal because how can you say this and that is required and this is the time line for documents when you benefit plans do not say that anywhere. I was told by BCBS FEP that I go by whatever the benefit plans state that's what they follow.
I am surprised that you were told all of this. The benefit plan is for both Basic and Standard.
I have Standard.
on 8/6/08 5:30 am - ypsilanti, MI
I called insurence company AGAIN and asked questions. AND got a different answer and the answer is conservative mesures but doesnt require PCP, or WW JUST SAID CONSERVATIVE MEASURES this is killing me folks.
Hockeymom87 · 0 replies · 608 views
