I am an R.N., C.C.M. with Anthem Central Centers of Excellence for Transplant. Part of my daily responsibility is to educate our members if they are using out of network benefits for transplant or, as in this case, had no benefits at a facility where member was referred for a heart transplant, as he was an HMO. The family was from India and their ability to communicate was good as I was explaining to the member that he had no benefits for heart transplant at the current facility and what his options were. During this conversation, the wife came on the phone to listen and ask questions. She immediately stated that they have no money, her husband is on disability, used to have a very good job but now with a Medicaid managed product, they have three children and must use food stamps. States she went to pharmacy to have his Coregard, Nexium and other drugs filled which normally are free and this time told they were told they had an $80 co-payment. Member, the husband, immediately stated that their medication should be at no cost. We discussed what might have caused the co-payment and at that point they both became so excited it was difficult to understand what they were saying. They asked for my help, could I do anything? States they have called customer service several times and just don’t understand. Yes, I will call their customer service and see if I can find out what their benefit is for medication then call them to let them know what I find out.
In speaking to the customer service representative, she looked up his medications and stated that on his policy if the doctor orders generic drugs they are covered in full. She stated that if he ordered brand drugs, as in this time then he must call a specific pharmacy 800-number, which she gave me, and discuss the rationale as to why member must have brand names. If the doctor receives approval for ordering the brand names versus the generic, than these will be covered at 100 percent also.
In my call back to family as follow up, I explained my conversation with the customer service representative advised that the doctor needs to call the 800 number to attempt to get the brand name drugs approved for them so they can be covered in full. The wife was so excited and began to thank me over and over again for my help. I offered to call their ordering doctor if they would give me the name and number to advise of the number and explain the situation. The member took the number where the doctor should call and preferred to call doctor himself. Again they both thanked me over and over again for this help, stating, “We are new to plan and just did not know where to turn and get help and you have helped!”
Yes, this case should have been a simple 30-40 minute call and instead was almost two hours. But how satisfying to help a family that was in such distress emotionally and financially, let alone the illness of major heart disease. These are some of my daily blessings of my work as a case manager.