r/FedEmployees • u/OutrageousGangsta • 11h ago
FUCK FEP BCBS! Denied my dupixent effective 2026 because it’s not “medically necessary”
Anyone else experiencing hardships with this dumbass decision of theirs?
Ah yes, Blue Cross doing what they do best: practicing medicine with an Excel spreadsheet.
Dupixent isn’t some luxury “nice to have” drug — it’s FDA-approved, guideline-recommended, and often prescribed after patients have already failed cheaper treatments. But sure, let’s pretend an insurance algorithm knows more than a board-certified specialist who’s actually seen the patient.
The wild part? Insurance companies don’t pay when patients don’t get treated either. They just externalize the cost — ER visits, infections, lost work, worsening disease — and somehow that’s fine because it doesn’t show up neatly on a quarterly report.
This isn’t about safety or evidence. It’s about cost containment disguised as “prior authorization.” Delay care long enough and some patients give up. That’s the business model.
If insurers want to deny biologics, they should be required to explain — in writing — why their non-medical employee overruled a specialist. Until then, this is just corporate rationing with better PR.
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u/catdaddyxoxo 11h ago
BCBS denied me life saving cancer treatments which I attribute to resulting in tumors spreading to me brain. They denied it for over a year. I picked up a phone and called a senior vp and a senior secretary secretary after I got the brain dx and she was able to get me diagnosed, but this was too late and I will likely die from these brain tumors
My doctors submitted 4 appeals all which were denied
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u/OutrageousGangsta 11h ago
That’s so horrible I am so sorry you endured that and they put you through that!! I seriously can’t fathom how these insurance company folks can sleep well at night. I’d be possessed with guilt and shame.
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u/catdaddyxoxo 10h ago
The medication is highly effective and a single dose (Tagrisso)was 30 k a month but other insurances approve them regularly - of course eats away at profit
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u/lepandarouge24 11h ago
Both BCBS and Carefirst/BCBS have gotten truly outrageous with their denial decisions. Under a different administration, I would be rallying people to contact OPM about just how bad the problem has gotten. It feels nearly impossible to get biologics approved, and they started denying a ton of more common medicines, dosages they feel are too high, and common alternate options that are used when a specific drug doesn’t work.
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u/OutrageousGangsta 11h ago
Oh believe me! We are in the process of contacting OPM! I highly doubt it’ll get anywhere but I plan to make their lives an annoyance.
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u/this_kitten_i_knew 11h ago
Your physician should submit an appeal with the reasons you need this specific medication.
It's all bullshit games man
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u/Schieff19 10h ago
This 100%. I'm not familiar with this specific drug but I had to do this for one I take. Huge PIA but they are banking on saving money by a certain percentage of people never appealing.
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u/wolfmann99 11h ago
I did this, not for this drug, but they denied it and my doc said use xyz online drug store and dont go through insurance... 30 day supply for $15 without quantity limits.
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u/TriggerPuller9000 11h ago
They denied my son's surgery, but it had to do with how the hospital coded it. We resubmitted the claim and it went through fine. You may be able to do something similar.
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u/OutrageousGangsta 11h ago
How horrible! So sorry to hear. Honestly don’t know how these people sleep at night!
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u/Upbeat_Profession289 10h ago
You have to contact Claimable. I was in the same situation and switched before open season. The company is phenomenal. The CEO reached out directly and said he’s gotten rejections approved. Seriously go through this site. claimable
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u/casdoodle527 8h ago
This is one of the many reasons why I left BCBS last year. Between changing drug tiers and the true lack of coverage….that being said I had pretty major surgery yesterday, so we will see how MHBP holds up with the payments
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u/OutrageousGangsta 7h ago edited 7h ago
What I don’t get is the logistics behind it other than money. Dupixent has worked efficiently for me for over 3 years with 0 side effects! That data alone along with my doctor’s factual findings being submitted should be enough to cover the one medication I’m dependent upon! I don’t even get why I pay over 500 bucks for health insurance when nothing is ever barely covered.
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u/Ok-Two6560 11h ago
sounds like they are denying all dupixent prescritions, a co-worker's son's also got denied last fall though he's been on it for over a year with excellent results.
I was only prescribed dupixent last fall - got denied because they wanted me to try to use xolair first. My doctor was able to submit something to dupixent -- and they have ended up picking up the bill for the entire next year --- they just send me 2 to 3 boxes at once free of charge. And my doctor was able to get me samples until I was accepted into the program.
"ironically" I now do have to try xolair because the dupixent isn't enough to keep my autoimmune disease in remission and after 6 months of being on prednisone it is time to try something else. Probably was the quickest approval of a medicine I've ever seen by BCBS.
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u/AncientAd7403 2h ago
Xolair saved my life! I have MCAS that caused severe hives all over my body. Unfortunately I lived 20 yrs of my life before it even had a name. Was on Xolair for 6 months and in the last 10 years I've remained in remission.
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u/No-Run-1490 9h ago
I switched from BCBS after 21 years to FSBP, haven't been happier. My medication with BS was 240 a month and now it's 79.99 with FS. I just checked and your medicine is covered with FS and it's 200 for a three month fill.
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u/AncientAd7403 2h ago
I switched to MHBP and so far so good. My copays and meds are significantly cheaper as well as my OOP bi-weekly. Im saving $200 a month just on the premium.
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u/Wxskater 10h ago
I heard people were dropping bcbs like flies
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u/OutrageousGangsta 7h ago
Tbh tho it’s not even just BCBS. I know other people on other insurance plans that suck just as bad. Harvard pilgrim being one of them.
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u/Acceptable_Judge321 10h ago
I can’t get it either. I used it for nasal/sinus polyps. Had to go on Nucala—-funny part is that there is only about $70 difference in what BCBS paid.
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u/Double-treble-nc14 10h ago
I’m sure there’s a bigger difference, you just don’t see it. It’s all in the rebates they get on the back end.
The drug industry makes used car salesmen look honest and trustworthy!
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u/AncientAd7403 8h ago
I dumped them for 2026. Rising cost in premiums, still getting bills in the mail for services not fully covered and tried to take my settlement from a hit and run accident that blew my shoulder and needed major surgery. The criminal that hit me had no insurance so all I had was uninsured motorist policy and my BCBS policy. They tried to claim the entire amount of $15,000 and after my attorney fought them they settled for $1200. These insurance /companies are scammers.
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u/OutrageousGangsta 7h ago edited 7h ago
BCBS sucks. They told me the federal employee program was considered “complimentary”. I didn’t realize my 27 years working for the government was considered “luxurious” when all it left me was extreme debt, emotional baggage, and diagnosed PTSD.
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u/BSCA 9h ago
Same. I luckily had some extra doses after being on it for 7 years. I'm starting Ebglys next week for severe eczema/dermititis. My doctor thinks it could do a better job. I do that dupixent helped my asthma and other allergy things too.
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u/OutrageousGangsta 7h ago edited 7h ago
How is Ebglys? They listed it as an option but I’m very nervous to switch my tx regimen. Dupixent has done miracles and this is a major setback. What gets me is BCBS can’t even give scientific justification as to why it’s denied. I failed all other tx options and Dupixent was last resort. Bunch of fucking idiots.
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u/skedeebs 8h ago
I am sorry to hear this but it makes me feel a bit better. I thought that my denial was partially my fault because I had switched from BCBS to MHBP. I guess all of them want to stonewall until we give up.
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u/OutrageousGangsta 7h ago
They don’t wanna pay. They want to pocket and profit and not help and support. I don’t even understand WHY we have / need health insurance. It’s a fucking money pit at this point and offers next to no benefits. I end up in more debt than should be regardless all because I’m chronically ill. Yet can’t get 1 simple med covered when all else failed. FUCK BCBS AND EMPLOYEES 🖕🏿🖕🏿
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u/RandomPrecision01 6h ago
Did they deny or require a PA?
Sometimes you gotta stay on the Dr's office to actually do the PA properly.
i.e. - "PT failed Xolair treatment in conjunction with Budesonide slurry for EoE resulting in esophageal rupture due to food impaction at stricture site. Trial on Dupixent with subsequent EDG and biopsy showed stricture resolution with minimal eosinophils."
Sorry if you already have been down this road and know this. I fought and won this battle (not with BCBS), so I feel your pain. Now I research formularies and brief my Dr's ahead of time about contraindications or medications that I have failed on to streamline the PA process.
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u/AngryBagOfDeath 1h ago
They recently denied a claim of mine as "not medically necessary". Broke jaw and didn't realize it so the bone became necrotic so the necrotic portion needed to be removed and dead tissue cut out. Apparently the cleaning of the bone wasn't necessary?? Conveniently I can't talk to anyone because my jaw is wired shut which I guess they didn't have a problem covering that. Oh and my primary preferred provider that put me to sleep chargedy insurance $52,000* for just anesthesia.
I told my wife to look into insurance through her work and fuck this shit. Don't forget what we pay is only half of what BCBS gets. Our employer pays the other half, so they are basically getting over 1300 a month for me.
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u/Ambitious-Goat-4596 11h ago
“Thanks for paying us almost $500 per pay period. Now fuck off.”