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$30,000 Pharmacy Claim Reduced to $0

Tom had concerns about the health insurance policy he purchased through his state’s exchange. He felt he wasn’t getting the best value for the amount he paid in monthly premiums. During our conversation, he shared that he has a chronic illness and his wife was to have a baby boy in the coming weeks. We quickly learned that the medication regime his doctor had advised him to begin required prior authorization. The doctor’s office didn’t initiate the authorization, although they’d told the patient they had. This wasn’t brought to CarePartner’s attention until the client provided full disclosure about his frustration with his physician’s staff some two weeks later. We got on the case and outreached to the Pharmacy Benefits Manager (PBM) and to the provider’s office to ensure clinical authorization forms were sent. Unfortunately, the doctor’s office drug their feet and even sent in the request on an outdated authorization form for client’s old insurance. This was a $30,000 medication, so the PBM needed everything to be forwarded correctly.

We provided the client a great deal of education on his pharmacy benefit because he thought he’d have to fulfill 50% of the cost of the medication based on specialty drug cost. What he failed to understand was his Out of Pocket maximum was $1,800 a year and not 50% against $30,000! Even better news, he had already met his maximum for the year!

Two days later, Tom was able to pick up his $30,000 medication for $0!

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