- 2,402
I got a hold of a member’s wife recently who is cancelling his MA only premium giveback policy (Veteran) to enroll into a regular MAPD for June 1. Reason given is so that the mb can get rx coverage through the MAPD.
The rx in question is an EXPENSIVE OPIOID (Nucynta) that is not on anyone’s Formulary, ie, most likely a Tier 5 formulary exception that would need some work on the part of his Doctor’s office.
What I then found out was that she ADDED her husband on to her Federal BXBS policy for ~$200/mo, which is actually covering the rx for $50/mo through October! She never cancelled the Humana MA only policy when the husband was added until now (May 31).
I told her that she would be better off with A/B ONLY as primary with the retiree coverage as secondary (since we know that the rx is already covered thru October).
What is the saying about “leading the horse to water?”
If they proceed to the new MAPD on June 1, would BXBS look to the MAPD to pay for this expensive Rx since Rx coverage is now part of the benefit?
If Humana MAPD refuses, would BXBS ALSO refuse to cover it because they are expecting Humana to cover it?
I don’t think that it was an issue before since the previous Humana MA didn’t offer rx coverage in the first place (and neither did VA), making the BXBS a primary.
I suppose that I will find out sometime this month.
The rx in question is an EXPENSIVE OPIOID (Nucynta) that is not on anyone’s Formulary, ie, most likely a Tier 5 formulary exception that would need some work on the part of his Doctor’s office.
What I then found out was that she ADDED her husband on to her Federal BXBS policy for ~$200/mo, which is actually covering the rx for $50/mo through October! She never cancelled the Humana MA only policy when the husband was added until now (May 31).
I told her that she would be better off with A/B ONLY as primary with the retiree coverage as secondary (since we know that the rx is already covered thru October).
What is the saying about “leading the horse to water?”
If they proceed to the new MAPD on June 1, would BXBS look to the MAPD to pay for this expensive Rx since Rx coverage is now part of the benefit?
If Humana MAPD refuses, would BXBS ALSO refuse to cover it because they are expecting Humana to cover it?
I don’t think that it was an issue before since the previous Humana MA didn’t offer rx coverage in the first place (and neither did VA), making the BXBS a primary.
I suppose that I will find out sometime this month.
