[BCHusband]

I'm posting in case this helps someone else in similar situation and to get feedback to improve letter. I deleted personal information for privacy.

To:
Carefirst BlueCross BlueShield - Member Services
Attn: Manager in Member Services
PO Box 644
Owings Mills, MD 21117-9998


Subject: Is the treatment recommended for my wife covered under our
Carefirst policy?

Patient: (my spouse)

Member: (me)

Diagnosis: Breast Cancer, Code 174.8
Recommended Treatment: Herceptin, Code J9355
Infusion Procedures: Codes 964.12 and 964.10
Treatment Schedule: to begin 23.November.2005

Doctor: (our ONC in Virginia)

Member Services Manager,

I’m writing this letter as a follow-up to our conversation from earlier
this afternoon to find out if my Carefirst Policy covers the treatment
recommended for my wife. Time is of the essence for Carefirst to provide
a definitive and clear response to the subject question as my wife’s
health is at risk and as the treatment is scheduled to begin in three
weeks. It is critical for us to know as soon as possible if the
recommended treatment is covered by our Carefirst policy as we cannot
afford to pay for the treatment otherwise. Further, if our policy does
not cover the recommended treatment for my wife’s diagnosis, we will
then need as much time as possible to explore alternative treatments
that are more affordable yet equally effective.

As you’re aware, I was on the phone today for over an hour either
talking with a Carefirst Member Services representative or waiting on
hold while a Carefirst representative was transferring me to other
departments or gathering information. Notwithstanding the fact that I
provided both the diagnosis and treatment codes, I was not provided a
straightforward answer to the subject question. Rather, I was told by
Carefirst representative's that there is no way for us to know for sure
if our policy covers the recommended treatment until after the treatment
starts and our doctor’s bills are processed through Carefirst’s system.

Given the estimated cost per treatment, the weekly treatment schedule
and the amount of time that typically elapses between the Date of
Service and our receipt of an Explanation of Benefits, we could easily
end up being personally responsible for tens of thousands of dollars in
bills before we, as the insured, our informed by Carefirst if our policy
even covers the treatment. We just simply cannot believe that Carefirst
requires us to assume such a financial risk and personal liability when
Carefirst has access to the diagnosis and recommended treatment weeks in
advance before the first cost is incurred. Is it unreasonable to want to
know in advance if our policy covers the treatment for my wife’s
specific diagnosis?

About five years ago, I selected Carefirst for my family’s medical
insurance based largely on your company’s reputation for quality of
service. I’m now requesting that Carefirst live up to its reputation and
let us know if my wife’s treatment will be covered in advance of the
treatment being administered. Please relieve my family of the undue
hardship and burden of being asked to begin treatment before we even
know if the treatment is covered under our insurance policy.

Please contact me at the number above should you have questions or need
additional information. Also note that our doctor’s office number and
POCs are listed above should you have questions of them.

Sincerely,
BCHusband

Copies:
-ONC
-Virginia’s Bureau of Insurance