Bcbs highmark 104

Family got new insurance plan this year through Highmark and it came with a $250 wellness card. What the heck do we use this on? Everything I’ve tried so far has been denied. We don’t belong to a gym so can’t use it that way. Can it be used at Dick’s Sporting Goods?

I’m seriously considering the surgery because I’ve tried a lot of diets, calorie deficits, exercise routines and medications to aide in losing weight and nothing has worked. My PCP is on board but she let me know that a lot of times they make you lose weight before getting the surgery. I’m scared because nothing has helped me lose weight… 🥺even giving up junk food and pop (which is my vice). I have Highmark BCBS and have a feeling they’re gonna do the same thing… I just don’t wanna get my hopes up and then not be able to schedule due to stagnant or nonexistent weight loss…

I have a bladder condition that causes urgency, frequency, pain, & is quite awful to deal with. I have to stop the medication that's kept it in check because it is damaging my retinas. My urologist had me try My doctor had me try mybetriq, but it raised my blood pressure way too high.
She then prescribed Gemtesa and my health insurance, Highmark BSBC in Minnesota, required a prior authorization, which they denied saying my diagnosis is not approved by the FDA for this medication.
How do I go about filing an appeal?

I have the opportunity to go with my new employer's health insurance plan (United) or stay on my husband's (BCBS). I had UPMC insurance until January, so all of my usual doctors are actually with UPMC. Some are in-network with BCBS, but some are not. When I search the United website, it looks like all of my doctors are in-network. The plans being offered to me are otherwise pretty much identical in benefits and cost. I'm 32F, healthy, and only need to do regular check-up things: PCP, OBGYN and I see a neurologist yearly for migraine treatment. I also take a weird name-brand birth control pill (Slynd) due to my migraines. It's been fully covered so far with BCBS. There is not a generic option for this drug.
I've read some horror stories about United wanting prior authorizations for medications, testing, etc when I've not really heard that about BCBS. What have your experiences been like with either plan? Which would you choose if given these options? TIA!
EDITED TO UPDATE: Always check your benefits closely before switching insurance plans! I'm glad I did. United Healthcare would not cover Slynd on the plan I was offered with my employer, so it looks like I'm sticking with my BCBS plan. I know I could have other options if I was really, really stuck -- like considering switching pills, getting my OBGYN to submit the authorization for medical necessity and then using coupons to pay for what's not covered -- but none of that makes sense when I can just stick with BCBS.
Thanks again to all who voted and gave their input. :)
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I have an Highmark BCBS through my employer. It has a $1,300 deductible (which I met) an out of pocket maximum of $4,850 (which I have met $78.26) and a total out of pocket maximum of $6,150 (met $2,072.54). I am so confused.
I have had a busy year, medically speaking, and have more stuff I want to get resolved but I am trying to see if I can afford this. Several of my doctors are in a group that switched to hospital based billing this year, if that makes some of the number make more sense.
Short of calling the insurance company and having them explain it I didn’t know where else to look. I googled but I cannot tell why I have a different maximum and total maximum. My old insurance was Cigna through the marketplace and I didn’t have this confusion.

Hi All, hoping to get some isight with choosing new health insurance for my son and wife. My company is currently offering two different plans, BCBS Gold Full PPO 0/25 with zero deductible and out of pocket maximum of $8,500 per individual per year ($104.46 per pay period). The other is BCBS Platinum Full PPO 0/10, zero deductable and $4,700 out of pocket max ($232 per pay period). Wife and I are fairly healthy and don't typically have large medical bills, our son is 5 months old, so no more hospital bills etc. Does anyone have any thoughts on suggestions on what would make most sese. I'm leaning towards the 0/25 because of cheaper premiums and the expectation that we won't have a ton of out of pocket expenses regardless. Any help wuld be much appreciated!

I can't locate how to submit my FSA bills to Highmark BCBS of PA. Any suggestions ? I have filled out some forms I found on-line, but can't find an email address to send them. Need to submit today.....thanks....

Some of you may have seen me post about my FIL a week or two ago. He had a severe stroke and has been in the ICU since 2/19. However, the hospital wants him out, as he's medically stable and really doesn't need intensive care (he's in the ICU because he's on a vent, and they can't care for patients on vents in other hospital units). Unfortunately, his Medicare Advantage Plan (Highmark Community Blue Signature) is denying the pre-cert needed to transfer him. We had a bed ready, but now the facility has no beds b/c we've been dealing with the insurance.
His hospital caseworker suggested we switch him to Original Medicare since the enrollment period runs until 3/31, as Original Medicare doesn't require a pre-certification. However, if he's on Original Medicare, he'll need a supplement and a drug plan. It's my understanding that if you don't switch back to Original Medicare and get a supplement within the first year of having Medicare Advantage, you have to go through medical underwriting to get a Medigap plan. I don't see how anyone will ever approve him...he's had a stroke, congestive heart failure, chronic osteomyelitis, and a bunch of other serious/expensive conditions. And if they do approve him, it'll be a bazillion dollars a month, which we don't have.
Can anyone think of other options? The Medicare Advantage Plan is denying the request for pre-cert because they said he needs "continuing acute care." We want to send him to a long-term acute care hospital, and his doctor did a peer-to-peer review with BCBS to tell them he's medically stable and doesn't need the care provided by the hospital he's in now, but they won't budge. The appeal has been denied twice.

I have health insurance through my husband's employer with Highmark Blue Cross Blue Shield and back in 2023, I was really sick with a post covid-19 sinus infection. I went to the Highmark BCBS website, where it showed that I could get a telehealth appointment immediately through Well360 Virtual Health and it was covered under our plan. I set up an appointment and was quickly connected to a healthcare provider chosen by Well360 Virtual Health, where I had a five minute appointment and got a prescription for a sinus infection.
I was very surprised to find out, almost three weeks later, that the visit was processed as an out-of-network visit according to the EOB. Considering that the insurance website said the Well360 Virtual Health service was covered by my plan and considering that you can't choose the provider because the app connects you to one so quickly you can't verify if they are in-network, I thought the provider was automatically in network.
I appealed the claim, asking it to be processed as in-network, with a screen shot of the website and pointing out the fact that it was Highmark's own app that picked the provider so quickly that I couldn't research if they were in network.
My appeal has been denied. They explained that, according to our PPO agreement, if you receive telehealth services from an out of network provider, it is processed as out of network. Well, I wasn't given the opportunity by Highmark itself to check to see if the provider their own app selected was in network or not.
I can filed a 2nd level appeal, do I just restate my reasoning and see what happens? Is there more than I should be pointing out? Or is it useless for me to try? I would appreciate any advice you can give me. Thanks.

I’m not sure if I should ask here or in the general ftm sub but I just need some help 🙏 Apologies for being very long as well, it’s been a hard day.
Important info before I continue; I live in Pennsylvania, my insurance is Highmark BCBS (My Priority Blue Flex PPO Gold), I do not want to/cannot travel out of state given my transportation, and I cannot pay out of pocket.
So it’s been days of going on and off of trying to find a surgeon, was able to get a list of all the ones that are listed as in network, 7 total…but given on how many have mixed reviews/results from what I’ve seen on here and if they don’t take insurance in general..that’s pretty much left me with 3-4 options and they still seem to be a 50/50.
Now this part I’ll say that I haven’t reached out to anyone yet, some can only be phone calls which give me extreme anxiety plus my work hours interfere a lot with free time. So im going based on my own research which is basically just reddit and a few websites.
Ideally, I’ve heard great things about Dr. Katherine Rose but she isn’t listed as being in network (even though the website says they take my insurance?) so…that could very well be mixed messages or she really isn’t in network and im out of luck. Also seen a few good things about Dr. Katheryn A. Brandt but again, can’t find that she’s in network or..any insurance info at all.
My In Network choices are now at:
Dr. Bryan Circuto , Dr. A.H. Jahromi , Dr. Jared Liebman, Dr. Joseph Serletti.
There’s also Dr. Ivona Percec but along with all these guys I’ve seen some mixed reviews and it’s making me very hesitant about reaching out to any of them.
I’m not sure what to do, I just want to have a good pick and be done with this, I’m very tired.
How are you supposed to find a good surgeon with limited picks??

Is there a reason why I got a notice from Highmark BCBS explaining to me how they won't pay for diagnostics and bloodwork I got done by my primary care doctor even though my insurance is with Anthem/Empire BCBS? Has anyone else experienced this?

I recently was prescribed Zepbound and we are waiting for my insurance to review the PA my doctor sent over. Now I saw on Highmark’s website that they do not cover weight loss medications, however I’ve seen success stories of people actually getting it covered through Highmark despite them having Zepbound listed as a medication they don’t cover. Anybody have this experience? Thanks!

I’m the most recent victim of the machinations of SaveOnSP. My company switched insurance carriers to Highmark BCBS, and they offer SaveOnSP, which is apparently a scam sort of company. They are being sued by Johnson & Johnson because they are a copay maximizer company. Basically, they try to squeeze the pharmaceutical company’s patient financial assistance program for all they can and STILL want you to pay fully too!
So they put in a stop order for my Stelara and tried to force me to join their optional program. After several calls (and a lot of misdirection on their part*), I realized there was literally no benefit to me on my high deductible plan. So I unenrolled, and they spent days still trying to stop my Stelara order.
Finally, I was able to get SaveOnSP and the pharmacy on the phone together and get this resolved. I’m going to pay out of pocket and get the reimbursement just so no colluding interests try to go after my financial assistance again.
Hopefully it all goes through just fine. 😭 As one last push, the pharmacy told me I’d be responsible for 30% coinsurance still because it’s a specialty medication. (They’re in cahoots if I didn’t make that clear earlier.) But I know it can’t be true because my deductible is my out of pocket max. But it still got under my skin, so I’m worried.
*they said IRS has ruled I have to pay my own deductible. They said at the end of the year (after I met my max out of pocket??), they would pick up all extra costs. They said after I met my deductible (which is all I pay), they would pick up the 30% co-insurance. How generous!

My husband's employer provides health insurance and, since the beginning of the year, they have been denying every single claim involving a doctor's visit, claiming we don't have active coverage when clearly we do with Highmark BCBS.
I've tried calling them and messaging them via their patient portal, where I'm told we have active coverage and they don't know what the problem is. They say the doctors are in-network and they will resubmit the claims for adjustment, which will take at least 6 to 8 weeks. Meanwhile, we're getting bills for hundreds of dollars!
My husband's employer has been useless trying to figure out the problem, stating they don't understand the issue. His union has been of no help so far either. I complained to the Minnesota Department of Commerce, but the complaint hasn't even begun processing yet.
Who else can I complain to? Attorney General's office? A federal agency? This is totally ridiculous! One of my husband's coworkers had a surgery called off because the hospital was told the employee doesn't have active coverage!

I’m in private practice in PA and currently have self-pay clients only. I’m considering taking insurance as my caseload is small and I want to increase business. I’m looking into the following: Highmark, Independence BCBS, Aetna, and United.
I’m nervous about all of the problems that arise from insurance and not getting paid etc… so I am hesitant to make the jump.
I’d appreciate any advice or just curious about anyone’s experience with it. Thank you.
*note - if I did go with insurance I’d probably only take one or two but nothing more.

Hey yall. I recently started looking into GLP-1 medicines and saw that Zepbound is more available than Wegovy. Spoke with my doctor and they prescribed 2.5mg of Zepbound. I’m now waiting for Prior Authorization and have a Highmark BCBS plan and the formulary used is Express Scripts. How long did it take for others to have prior authorization approval? Highmark says it can be up to 15 days.
I have a BMI higher than 40 and PCOS.

After seeing an ENT for temporary hearing loss believed to have been caused by TMJ issues, my dentist recommended a night guard at my follow up appt. Delta dental does not cover any of the night guard cost (several hundred dollars) and I’m wondering if I might be able to get my medical insurance (highmark BCBS) to cover it.
Has anyone had any experiences with this? What was the process like? I assume I’d need to get documentation or a prescription from my ENT for this to apply. Thanks in advance!

Hey all! I was recently prescribed Aklief to help with my skin texture and acne concerns. I just went to the pharmacy to pick it up at CVS and they told me after insurance (BCBS) it would be $104 🙃 I called my dermatologist’s office and left a voicemail to discuss an alternative but wanted to hear what you guys use! I can’t pay over $100 for a tube of cream 😂😭

I need help I cannot find Wegovy 0.25 in WV anywhere? Is there another option? I have Highmark bcbs of wv

I posted this on zepbound page but was hoping to get more insights.
So - this is my new insurance, in the past I had optumrx/ blue cross. Whenever a PA needed to be sent these teleheath services were able to do it no problem. Now with this one everyone seems to have a problem, I joined one thinking my Mounjaro script would be approved with Reddit search but the NP had so many issues it took her two weeks to get the PA over and she had to submit the PA over the phone. I thought they were just quacks so I went back to HelloAlpha since I had success in the past and now my plan covers zepbound. This time they want to call my pharmacy and have them send the PA over. Is that right?
Why is express script giving me such a hard time?!

So - this is my new insurance, in the past I had optumrx/ blue cross. Whenever a PA needed to be sent these teleheath services were able to do it no problem. Now with this one everyone seems to have a problem, I joined one thinking my Mounjaro script would be approved with Reddit search but the NP had so many issues it took her two weeks to get the PA over and she had to submit the PA over the phone. I thought they were just quacks so I went back to HelloAlpha since I had success in the past and now my plan covers zepbound. This time they want to call my pharmacy and have them send the PA over. Is that right?
Why is express script giving me such a hard time?!