We all need our own copy of our Medical Plan

December 4, 2010 at 6:16 pm

Well, I see Goodney answered while I was typing…. but here goes anyway.

In my case I have a Summary Plan Description. To date I have not needed the entire Medical Plan.

This case really interested me so I found this:


This let providers (that’s me and you, right?) search for BCBS NC Medical Policies.

So, I entered “IVIG” and got this:


Which is the BCBS of [B]North Carolina Corporate Medical Policy Immune Globulin Therapy[/B] which was last reviewed 8/2009. This implies it is a current document.

Note, that similar to an Aetna Policy I posted some weeks ago, it details exactly what is required to be eligible for IVIG, including the required use of IVIG only for FDA-Labeled Indications, which means no off-label use is likely to be approved. Of course, it also lists when IVIG will not be approved.

In this case the poster has shared that the BCBS letter included the following language: “[I]…Initial evaluation of the members neurological condition is not provided. Records do not show a presence of a covered indication per coverage policy. IVIG is considered investigation for members condition.[/I]”

Initial Evaluation…. What does that mean? A Doctor’s Office somewhere did not provide required documentation.

Records do not show…. What does that mean? A Doctor’s Office has submitted a diagnostic code for a condition, not CIDP, which is not covered. Why do I say, not CIDP? Because CIDP is covered. Refer to the Plan above.

Finally, if you cannot open the linked .pdf file then you could download the free adobe reader.