Case Study: Hi Vikki

a glance). Mrs. Zwick should go to a Medicare Network pharmacy to minimize cost. The

which she only pays $120.00 per month. Even though her health insurance covers the majority of her medical

pays 86% of the cost of generic drugs during the coverage gap. The patient may get a 50%

The arrangement did not work, as the son-in-law used Ms. Inez insurance for his diabetic supplies. She showed me her medications that were in his name.

requirement on the medication, and since we haven’t purchased the drug through Humana to this

First, I must assess Mrs. Jones understanding of her insurance plan. Is she even aware that she doesn 't have prescription drug coverage? According to Cohen and Villarroel (2015), "approximately one fifth (18%) of the $263 billion spent on retail prescription drugs in the United States in 2012

The carrier has denied coverage of Harvoni 90mg – 400mg as not medically necessary. There is a letter from the carrier to the member dated 11/20/2015, which states in part:

I agree with the statement that the patient could be wrongly charged. The insurance company is also likely to deny

Kathy has a weight bearing restriction in place, is currently utilizing a wheelchair for mobility, and is a hands on one person assist with transfers. Judy shares that the previous day Kathy and the physical therapist worked with Joe and herself on transfers into and from the car so they can take her to her scheduled appointment with the orthopedic doctor on Friday. Judy shares that it is expected that the doctor will modify the weight restriction at the appointment. Judy and SSA spoke about a time frame for discharge. Judy shares there is no time frame established. Per Judy, Kathy’s private insurance only has twenty days of physical therapy remaining in the plan and does not know what happens at the end of the twenty days if Kathy needs additional therapy. She has plans to contact Humana later this day to discuss Kathy’s insurance benefits. We discussed that Kathy believes she has an UTI and that a sample of her urine was taken before lunch for testing. We discussed that Kathy is satisfied with the Care Springs facility, the food served, and nurses assigned to work with her. During the visit, Kathy asked about Wildey staff and of all who was aware of her injury. We discussed her

The carrier has denied coverage of continued occupational therapy from 07/29/2015 - forward as not medically necessary. There is a letter from the carrier to the member, dated 03/29/2016, which states in part:

Hope all is going well. Please be aware HR is yet to received your benefits applications and as a result, your personal file its out of compliance. Please see me no later than Friday, 11/18/16 to go over the missing forms.

“You do not meet the coverage criteria as outlined in Geisinger Health Plan’s drug policy.

EMPLOYMENT UPDATE: Client is WECARE/FEDCAP exempt from work. Client submitted doctor note stating she cannot work due to medical problem.

The carrier has denied coverage of Harvoni as not medically necessary. There is a letter from the carrier to the member dated 03/09/2016, which states in part:

Profiled med (New prescription that CSA received that is not eligible to be refilled at the time the Rx was requested)