August 11, 2006 by bob.

Q. I have double coverage, my plan through my employer and I am also covered under my wife’s plan at her work. I have recently been diagnosed with early stage cancer and I want to pursue a treatment that is not recommended by either HMO. What can I do?

A. My first question is, why do you have double coverage? Unless both plans are available at no charge there is no reason to maintain two major medical plans.

You didn’t say why the HMO denied the treatment plan, so I have to assume they know more about your situation than I do. Despite the “bad rap” many HMO”s get in the press, they actually do a very good job of disease management. In many cases, even better than most PPO plans.

Unless you or your wife are an oncologist, they probably know more about what works in your situation than you do.

You do have several courses of action. The easiest is to allow your carrier(s) to map a treatment plan and minimize your out of pocket costs while taking advantage of their expertise.

You can appeal, and delay treatment. The appeal process is time consuming and waiting may cause your situation to worsen, decreasing the likelihood of a positive outcome. It may also leave you back where you are now.

You can pay for your treatment out of pocket while appealing. Keep in mind your appeal may still be denied in which case you have paid thousands for a treatment that would have been covered in full, or close to that, had you listened to your PCP.

If your appeal is denied, you can take it further to the state DOI. You may also want to consider legal action against the HMO.

All of these are costly, time consuming, and rarely have outcomes to your advantage. I might add that several studies have indicated that stress can affect the outcome in treating some illnesses.

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August 11, 2006 by bob.

Q. Why won’t company’s allow me to get the coverage I need? I am on regular medication for high blood pressure and high cholesterol. Every company I have applied to will not allow me to have a drug copay card, or will not cover my medications.

A. The answer is two fold.

You probably applied to the wrong company.

The carriers are not stupid.

Some carriers, but not all, will allow you to “buy up” your coverage by paying extra to have coverage for some pre-ex conditions. In these cases, you can have the coverage you want. The person that advised you to apply with a particular company was either uninformed or simply gave you poor advice.

And some medications, particularly those for cholesterol, are quite expensive. Carriers will not write your cover for $200 per month knowing they will have to pay out $400 or more in medication costs.

There are ways for you to offset your out of pocket costs for meds. One is with an international pharmacy source. Another is to look at some of the PAP’s (Patient Assistance Programs) such as those outlined here.

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