HMSA Drug coverage

[oceanpacific]

I got a shock today at Long's when I went to re-fill several prescriptions. One oral med had its usual $5.00 co-pay, another was $10.00. No surprises there. But, the third, which is injectible and in a pre-filled syringe, was billed to me at full retail, $254.35! :eek: I've used this medication before and it was covered back then. My co-pay used to be around $20.00.

So, tomorrow, I'll be on the horn with HMSA to find out why this has transpired. Ironically, my doctor had asked me yesterday if I wanted to DISCONTINUE this particular medication and I decided to stick with it as it has been effective.

I wonder if the changes in coverage on July 1, 2007 had anything to do with this?

[alohacandy]

I got a shock today at Long's when I went to re-fill several prescriptions. One oral med had its usual $5.00 co-pay, another was $10.00. No surprises there. But, the third, which is injectible and in a pre-filled syringe, was billed to me at full retail, $254.35! :eek: I've used this medication before and it was covered back then. My co-pay used to be around $20.00.

So, tomorrow, I'll be on the horn with HMSA to find out why this has transpired. Ironically, my doctor had asked me yesterday if I wanted to DISCONTINUE this particular medication and I decided to stick with it as it has been effective.

I wonder if the changes in coverage on July 1, 2007 had anything to do with this?

Are you with a group health plan whose new benefit year started in July? You should be able to get a list of HMSA's formulary for covered drugs under your plan. On occasion, I've found that drug stores make mistakes and key in the wrong code for a drug, see that it "isn't covered" and then don't bother to check further unless the patient brings it up. So first step...find out if it's a covered drug and at what tier of coverage....then if it IS supposed to be covered, find out why it was rejected and then proceed to have it corrected. I've helped several people get refunds due to pharmacy errors. Good luck!

[oceanpacific]

Thank you for the information.

I am in a group plan (State of Hawaii). I remember that last year, when I first got this, availability was limited (only Times pharmacy dispensed it) and they confirmed with HMSA on the eligibility before they filled it.

This time, I asked Long's if they carried it and was told they did after the tech checked their inventory.

Now, I wonder about senior citizens without drug coverage. How can they afford their meds?

[1stwahine]

Now, I wonder about senior citizens without drug coverage. How can they afford their meds?

It was discussed here: http://www.hawaiithreads.com/showthread.php?t=9073&highlight=AARP

Auntie Lynn

[helen]

The drug plan for the State of Hawaii (assuming one was covered by HMSA before which seems to be your case) got changed and new cards were issued by the union trust fund (and I can't remember the initials of the group). The cards were mailed out in late June.

Oh wait, I am assuming you are an employee of the State Of Hawaii? Or are you in a different medical plan that deals with just being a resident of the State of Hawaii?

[oceanpacific]

I spoke with HMSA this morning. Their explanation goes under the YOU LEARN SOMETHING NEW EVERYDAY category.

1) the change on 7/01/2007 resulted in drug coverage under a new carrier;
2) this medication is an injectible and classified under medical procedure, NOT drugs; coverage is by HMSA medical, not the new drug carrier;
3) Long's Drugs is NOT a contracted PPO with HMSA for medical coverage;
4) I have to send in a claim for re-imbursement by HMSA under medical;
5) HMSA will re-imburse only 70% of the charge AFTER applying a $100 annual deductible for non-contracted providers;
6) Times pharmacy would have applied a 10% co-pay ($25.43) and HMSA would have covered the balance as Times is a contracted provider;
7) my re-imbursement may be as little as $78.05, depending on the math:

($254.35 x .70 = $178.05, less $100.00 deductible = $78.05

Therefore, my "loss" for the convenience of going to my neighborhood Long's instead of driving to Times will be $150.96! There's a lesson for all: things are not necessarily what common sense dictates.

Ironically, two other medications I take which are "injectible" are classified under drugs, not medical procedure. Even though one of them uses the same screw-on needles as the medication at the center of this problem.

My coverage is as a family member of a state employee.

[GeckoGeek]

3) Long's Drugs is NOT a contracted PPO with HMSA for medical coverage;6) Times pharmacy would have applied a 10% co-pay ($25.43) and HMSA would have covered the balance as Times is a contracted provider;

And of course this raises a natural question: Walgreens

Certainly there's room for improvement at Longs. At minimum it would have been nice if they told before you payed so you could have hunted around for a better provider.

[oceanpacific]

And of course this raises a natural question: Walgreens

Certainly there's room for improvement at Longs. At minimum it would have been nice if they told before you payed so you could have hunted around for a better provider.

It's too late for me, but I should have refused it at the time. Once medication is dispensed, you can't return it, even if unopened. I'll have to "eat" this $150 "loss." OUCH!

I still can't fathom the idea that this isn't classified as a "drug." My other injectibles are.

[alohacandy]

Certainly there's room for improvement at Longs. At minimum it would have been nice if they told before you payed so you could have hunted around for a better provider.

I've found that many times Longs won't inform the customer as to WHY their medication did not go through their insurance (i.e. "We're not a preferred provider." "We didn't have the diagnosis code." etc.) Many elderly, less educated, or less fluent in English are afraid to ask and either just pay or leave without the medicine and without questioning. How many times have you shown up to pick up your medicines and it wasn't until THEN, that you find out there was a problem. A phone call would have hopefully resolved the issue...and probably would help with preventing the long lines that you often find at some of the Longs pharmacies. It's all about customer service.

[oceanpacific]

Well, I've submitted my claim for re-imbursement under "medical procedure." Let's see how much I get from HMSA.

[tutusue]

I heard from a friend last night (same friend involved in this thread (http://www.hawaiithreads.com/showthread.php?t=13168&highlight=canal+house)!!) that she picked up a prescription as she usually does from a local pharmacy (I didn't ask which one) only to be charged full amount ($85.) because of a new rule that that med now must be dispensed directly at Tripler (she's a military dependent). Up 'til that point she'd been paying $3. for it at a civilian pharmacy. I mentioned I hoped she refused the med and hele'd on over to Tripler. She kept it because she waited 'til the last day before she needed it and couldn't get to Tripler for a couple of days.

So, yes...when a pharmacy sees a drastic change they should make a courtesy call to the patient. If the patient has been informed in advance (usually by mail) the onus is on the patient. Still, good customer service should prevail.

[D'Alani]

Oceanpacific if you are a veteran sign up with the VA up by Tripler or check out www.myhealth.va.gov (http://www.myhealth.va.gov)

[oceanpacific]

Got the re-imbursement check from HMSA. Amount was $76.90. Close enough to my projected $78.05.

I'm not a vet, so no VA benefits for me.

[alohacandy]

Glad that you were able to get your check so quickly! :D

[oceanpacific]

It was quite timely and will cover some of my upcoming co-payments.

I'll be able to "recover" its impact on my finances over the passage of time. Chalk it up as the cost of "education."

All prescription medication = covered drugs ............... NOT!

Ironically, Time's just announced the opening of a pharmacy in my area.