PEBB INSURANCE CRITERIA

SO.....I haven't posted in a long while, because I have been ticked off with Aetna PEBB. So I went through all the pre-op criteria, saw the nut, the psych eval, all the 50 million test and was done.  Dr Srikanth's office sent all my stuff to Aetna Which at the time had a set criteria and I had fulfilled all of it, lost the weight I was suppose to and everything.  And Then found out that Aetna was not the criteria I was suppose to follow PEBB (Public Employees Benefits Board) had separate criteria that I had to meet.......which they had not yet posted on the web site when I had started this little trip.....I started my stuff at the beginning of January the 4Th to be exact, They had a meeting on the 17th and made some funky decision to change the criteria that the insurance company had to their own little club....so even though I met all of Aetna's criteria I didn't meet PEBB so I was denied.  PEBB wants you to go through a case manager and to use a state funded hospital so........I have to start all over again..............I am hot about it......And I can't pick my own doctor.  CAN YOU BELIEVE IT?????????

That sucks! I hope everything works out for you in the end!

Hi Charlotte.  Where are you from?  What part of the state do you work for?  I'm a PEBB employee also.  I started my process in January of 07, so didn't run into what you have.  I did have to go through a case manager.  Did you have to do the 6 month, lose 5% of your body weight with Aetna?  You may be able to show them proof and not have to start at the beginning.  As for the Dr., you have to go through a bariatric program that is a "Center of Excellence".  I know that they don't budge on that one.  I'd try to do a little more investigation with it and try not to get too discouraged.

tk

My husband works for the State and we live in Tacoma, yes I do have to lose the 5% but I am hoping they will just take proof from me for everything else.  The Center of Excellence is not the issue it has to be State funded hospital that I have surgery at.  So St Francis is out, I have to go to Virgina Mason or UW, the other choices are a hospital in Portland and one in Spokane.

Sorry about your discovery, that must be very frustrating and a huge shock!  You've got me nervous too now since I am in the process and my husband works for the state as well....and we've got Aetna.  I've lost my 5% so far. Next I have to go to a Center of Excellence for their program.  There are 4 that I could choose from.  Virgina Mason, Legacy in Portland, U of W or Sacred Heart.  I just spoke to my case manager a couple weeks ago.  I wonder what is up! Good Luck, please keep me posted! Debbie

The program at the one in Portland seemed nice, have you gotten your referal from the case worker yet.  You have to get that before you can go. I decided on Virgina Mason because they have an office in Federal Way which is pretty close to where I  live.  And they do Laproscopic surgery.  Which one are you thinking of? 

How Frustrating that must be for you!  I hope they will take into consideration all the work you've done so far.

Sorry to hear it's been such a problem.  I know how frustrating it is (I was initally denied in '07 due to not enough comorbidities (I had 1 and needed to have 2+).  I have Uniform PEBB and have been working with Riaz (my case mgr) since Jan 24, 2008.  They have changed the criteria from last year so that now instead of 2 cormorbidities you only need to have 1 and a BMI of 40+.  So at least that's a plus (more people can qualify :-) I was going to go to UWMC in Seattle (since I work there) for surgery but privacy (many of my coworkers would have access to my info) and the wait time were the reasons I decided to go to Legacy Good Sam in Portland.  I've had my initial appts in Portland and was cleared to see the surgeon's office (Dr. Jan Jay).  I'm waiting to hear from them to see when I can sched the surgical consult.  After that everything will be sent to Uniform and I will (hopefully) get approval to schedule surgery!  I'm just scared that Uniform will find some way to say no..... Alicia