A friend writes:
“Tufts Medicare Preferred on numerous occasions failed to give me cost and alternative information
related to Nucala (asthma) injections that I needed to make a reasonable decision. After three
injections, I received a bill for my first injection copay of $576.74 indicating a total of $1730.22. I had had
no previous indication of the magnitude of the cost – which Tufts knew but repeatedly failed to tell me.
Further they did not tell me that going to the next tier of the insurance would eliminate this cost.
“SUMMARY CHRONOLOGY
“On 1/2/2018 an allergist recommended that I start on Nucala to help relieve asthma problems.
“On 1/10/2018 I received written approval from Tufts that the Nucala injections had been approved; the
letter dated 1/5/2018 had no indication of its cost. Tufts knew of the cost and certainly should have let
me know, especially considering its magnitude.
“On 2/5/2018 I called Tufts to ask about the cost of Nucala injections. During the call I was told nothing
meaningful and left with the impression that if there were a copay, it would be under $45 per injection.
Further, I was not told that there would be no copay if I went to the next tier at a cost of $46 per month
(and could do that effective with the next month).
“I had Nucala injections in early Feb, March and April of 2018. It was only after the third injection that I
received a bill for the first injection copay of 576.74, implying I would owe $1730.22 for the three
injections I had had so far.
“SUMMARY
“Tufts had access to databases that show the cost of Nucala, and knew of the cost of this drug when it
pre-approved the injections for me. Yet, on multiple occasions, Tufts refused to let me know of even the
magnitude of my cost the injections. Further, they never told me that the next tier of the insurance
would have no copay. Had I had any idea, I would have refused the injections at least until I changed my
coverage.
“REQUESTED ACTION BY TUFTS
“Tufts should pay the cost of the three Nucala injections of 1730.22 (perhaps minus the three month cost
of the next tier of insurance of $138) AND immediately change their unethical practice to one where
they are up-front about costs rather than springing such costs on you ONLY AFTER the costs are
incurred.”
What we did
We asked him some follow-up questions. We also reached out to the press office at Tufts Direct and got no response.
In one of his responses, he asked the obvious question: If the medication has been approved, why doesn’t the insurer pay? Here’s his letter.
“I received a denial letter from [name redacted] regarding the rejection of my case, dated May 22, 2018,
“I wish to appeal.
“When all is said and done, Tufts had ample opportunity to let me know at least the approximate copay before I received the Nucala shots. Neither the letter advising me of approval of Nucala (1/5/2018) nor my phone call of 2/5/2018 gave me the slightest indication that the copay of this drug could be so expensive. I had no idea, and when I asked, I was given no indication. Surely Tufts knew of at least approximate cost and the likely high copay. Yet, I only got a bill, from Lahey, after I had three shots — amounting to a total copay of $1730.22 ($576.74 X 3). At that point, I stopped them immediately.
“If I had any idea of the high cost, I would never have started (saving me and Tufts considerable costs). Tufts had ample opportunity to let me know, yet never did, in spite of my requests.
“This I find to be misleading and unconscionable. Surely you could have been up front with me.
“My request is for you to credit me for at least most of the copay of $1730.22.
“Thank You for your understanding — and hoping also that you will revise your procedures to advise customers of co-pay specifics. “
He also wrote: “It appears that the Tufts Medicare Preferred plan I am on, Saver Rx, is the only one with a copay for part B drugs (which I now understand applies to Nucala). Thus, had I been told of the high cost of Nucala, I could and would have considered going to a more expensive plan (waiting for the following year if needed) with a $0 copay for part B drugs.
“
A little more on the appeals process
Finally, in an email response to my question about the chain of events, he wrote:
“The appeals process is long and well warped in favor or the insurance provider. The law apparently ignores ethics of even reasonable disclosure.
“An appeal to Medicare only resulted in a call from Tufts Health Care saying too bad. The appeal appears to be a sham.
“The appeal to Tufts direct had been appealed to Maximus Federal Services. They agreed with Tufts that they did nothing wrong. I am appealing that to an Administrative Law Judge (ALJ) hearing. That is ongoing, I’m not optimistic…
“Alternatives I am considering — perhaps the Massachusetts Attorney General office or Senator Warren’s office.
Perhaps the light of day on the internet — Yelp, Facebook or some such.”
(Update, April 2019: He wrote: “Hope you are doing well. It’s been a while, but on March 27, 2019 the Administrative Law Judge denied my claim (appeal). I have attached the decision. I think the “Analysis” on page 6 of 7 is telling – The judge seems to say that while Tufts did not break the law, fairness did not prevail. She seems to say that for equity, I could again appeal, this time to Federal court. ??”
