Loophole in Obamacare exploited – Pharmaceuticals- Coventry Health
Okay there is going to be some ambiguity and some math here so stick with me.
I process pharmaceutical claims everyday. I had some beginning of the year Med D claims that were $300-$500 higher than our calculator expected.
These are the main drugs for a specific diagnosis. The total drug cost is about $6,500-$6,800 per month (per shipment). We expect $2,300-$2,500 initial payments given the deductible, initial percentage, and going into the donut hole.
A brief explanation of Med D copays
There is typically a $325 deductible then an initial phase (usually 20 25 or 33%) THEN the donut hole hits. Drug price takes you into the donut hole you pay to get out of it.
For 2013 -----Initial phase goes to $2,970 then the individual pays 100% (less Obamacare discounts) until the individual and Medicare pay $4,750 out of pocket. In 2012 (Obamacare) there was a 50% discount in the donut hole paid by Medicare. In 2013 there is a 52.5% discount the donut hole is going away.
So these claims are a bit too high. I do an analysis of 35 claims (out of 1,500 on the invoice) and communicate this to my boss and to the pharmacy. You have heard of this pharmacy.
I was certain that the billing program at the pharmacy has switched the 52.5% the wrong way and applied the 47.5% to the patients.
What I found out was telling.
The Pharmacy representative (great lady who really solves a lot of problems FOR patients everyday) informed me that almost all of the claims were run through Coventry Health. They re-classified two mainstay drugs for a specific and kind of rare diagnosis as Non-Preferred drugs. Totally ridiculous. These are THE drugs for this diagnosis. Because of the re-class by Coventry it is not the donut hole that is effected it is the initial phase that changes. Instead of 20/25/33% it jumps up to 50%......in some states Illinois is 50%, Virginia and Ohio is 44% etc. I checked the Coventry website and randomly selected a few states and they were all over 40%.
I was stomping mad. My boss finally said to pay the claims for the patients we werent going to get Coventry to change this policy. The rep at the pharmacy intimated that she knew it was bullshit.
I found out the next day that many patients are calling in trying to find something other than Coventry to cover them.