Posted by Jennifer on October 9, 2000, at 3:12:50
In reply to Northern CA Insurance Advice--Racer, Greg?, posted by Abby on October 9, 2000, at 0:52:45
Abby,
I haven't worked up north for awhile, but I am a bit familiar with billing under those insurance plans. The one you are under now is really for students in an age group that has occassional illness and few chronic illnesses. It's just not set up to handle your type of situation. Pacificare depends on if it is the HMO or the PPO. I personally dislike the HMO, but the PPO is acceptable. Healthnet has the lowest reimbursement to CARE PROVIDERS besides Medicare in California. You may do ok with it, but may have trouble finding providers that stick with the insurance. I've seen a bit of a turn-over of providers with them. It all depends on your area. As far as Kaiser, it has greatly improved over the last ten years. You will still have to deal with all of the referral stuff, but at least just about everything should be covered. There just isn't a way around the referral business and capitation plans when California has the highest level of managed care in the nation.
If you have the choice of a PPO, and can afford it, I would take that route only because you would be free to make more of your own choices. Otherwise, try and call a few of the providers you like, and see what their office staff recommends. They are the ones that have to bill them and deal with their referral lines all the time, so they would know best.
As far as Blue Cross or Blue Shield...you may want to call them and see if they ever cover Zoloft if it's determined that it's the only med that will work for you. Sometimes insurance will cover these type of items if they have a letter from your physician stating the reason it's necessary. Also, when you call any insurance company, never take the answer of the first person. You'll need to go up to a "case manager" that is an RN and see what she says. Do that even if she needs to call you back. Keep bugging them, and then have them put it in writing.
One other idea...check online for the manufacturers of Zoloft and see if they offer free RX's to those in need. Most drug companies do, and you may be eligible. Good Luck! Jennifer> Could the Northern CA babblers please e-mail me describing their experiences with different insurers.
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> I am currently on a University Health Insurance Plan which I don't find acceptable, and I'm looking into buying an individual policy.
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> Under my current plan I have to go to Student Health Services first. They refer me out to prudent providers when necessary, but I wonder whether I would need to be in cardiac arrest for them to take me seriously. All services---lab tests, doctors visits, immunizations at the Student Health Service are not covered, though the fees are slightly cheaper than elsewhere. There is one psychiatrist, and I don't really like him. I don't think he passes Dr. Ivan's test as a psychopharmacology expert. He thought that 150mg of Zoloft was a very high dose. He's also off during the summer. Psychiatric care is really limited, but it is free.
> Prescriptions are discounted 50%. Outside mental health is limited to 40 visits per year, reimbursed at 80%, maximum of $50.
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> Which plans are more likely to cover pre-existing conditions, namely my depression, and any untested thyroid abnormalities?
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> What experiences have people had with Kaiser? Healthnet or Pacificare (the last one looks bad). Neither Blue Cross nor Blue Shield include Zoloft on their formularies. There's also a local one called Western Health Advantage run by doctors, but I don't think they sell individual policies.
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> Tips on navigating the system, experiences good and bad would be most appreciated.
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> Thanks,
> Abby in Cow Town
poster:Jennifer
thread:885
URL: http://www.dr-bob.org/babble/social/20000813/msgs/893.html