Monday, March 23, 2009

Don't Ask Me!

We just had an enlightening conversation with Candice from Humana's Prescription Review Department. Apparently this is an annual service provided by Humana to assess how (and if) the client's prescriptions are working together.

What we learned today:

  • Keith is still in Stage 1 of the prescription plan, which means that he has not yet reached $2700 in Rx benefits for the year. Approximately 25% of rx costs come out-of-pocket. However, that limit is rapidly approaching and Keith should enter Stage 2 coverage by about June 1st.
  • Stage 2 is the dreaded "donut hole" with no prescription coverage at all. This would not be a problem if Keith had Medicare Part D insurance, which limits the client's out of pocket costs to $100/month. However, he didn't anticipate the healthcare issues.
  • Once you are through the donut hole, you enter Stage 3 (Catastrophic coverage) in which Humana covers 95% of the prescription cost, with the remaining 5% coming out of pocket.

We did not have to deal with this last year because Keith spent so much time in the hospital and billing is completely different.

Confused yet? Yeah, so are we. I honestly don't know how people with less capability (whether due to illness, confusion or stress) handle this. The system seems to be designed to deliberately confuse and frustrate the client. And the people assisting you seem to realize this as they immediately give you new department names, 800 numbers and other potentially helpful tidbits to solve your problems. The bottom line, however, is "don't ask me!".

Here are the Humana support numbers she gave us, please feel free to share with everyone:

  • Prescription Review Status: Clinical Pharmacy Review Team 800-555-2546
  • If your prescription status is declined: Humana Member Grievance & Appeal Department, 800-457-4708

Once you are in the 'donut hole', there are two recommended prescription assistance programs:

We are still awaiting the 2nd round review of Keith's medroxyprogestrone prescription coverage. The doctor is sending another strong appeal for support and Candice noted that Keith's prior 10 years of usage should be a strong consideration in the board's decision. However, as always, the unspoken message was "don't ask me!"

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