This is an interesting and frustrating confluence of several InsureBlog themes: Pharmacy Benefits Management (PBM), transparency and consumer-centric health care. On the one hand, we're encouraged to become more "hands on" regarding our own care, to be more cost-conscious consumers with "skin in the game." On the other, carriers often put up major roadblocks that actively prevent us from saving both ourselves and the insurance company some major bucks.
And sometimes, persistence and common sense prevail. Here's the story:
Melvin and his family have been clients for many years. He early on bought into the Health Savings Account (HSA) idea, and has enjoyed both the savings that it represents and the ability to bring at least some of his health care under his own control. Recently, his wife was diagnosed with a serious (but thankfully not life-threatening) condition, the only treatment for which has been costing him over $600 a month. The good news is that this quickly eats up their $3,000 family deductible. The bad news is that he has to come up with the $600 every month for almost half the year.
A few months ago, he learned about a Canadian supplier that can provide the exact same medicine at about $100 a month. His carrier, Medical Mutual of Ohio (MMO), even has a claims form for just this circumstance. So, Melvin bought a 30-day supply in December (to cover Mrs Melvin until the Canadian supplies kicked in), and then a 90-day supply early this year, waiting the required 30 days before doing so.
He then downloaded and completed the rx claim form, and (as instructed) mailed it to MMO's Pharmacy Benefit Manager, Medco. What we didn't know at the time was that, even though the meds are covered, the process for this method required dealing directly with MMO, not Medco.
It took us several weeks, phone calls and emails, but in the end, Medical Mutual followed through, coming up with a workable, long-term solution. We know this because Melvin has now tested it, and everything went precisely as it should.
This is critical, because as more folks access alternative delivery options (such as from Canada or other exotic locales), these kinds of processes will need to be implemented. Melvin and I are quite happy with how Medical Mutual, once prodded, stepped up and did the right thing.
[Special InsureBlog Thanks and Kudos to MMO's Ed B and Regina D]