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Care Coordination Stories: Getting Medication when Insurance Ends

March 3rd, 2015

Insurance ended when a parent lost his job, but his child needed medication for a severe cardiac condition.

When a parent lost his job, his insurance ended and he wasn’t sure how he would be able to get the medication his child needed. His child has a severe cardiac condition. Without the medication, the child would need to be admitted to the hospital for medical management.

The family also had Medicaid (public) insurance for the child, but since their private insurance had been covering the medication, they were not sure how to get it. They were unfamiliar with Medicaid requirements for medication approvals in general, or the specific requirements for this particular medication.

The family’s Care Coordinator worked with the child’s physician  and nurse practitioner to get letters of medical necessity. Our Benefits Management and Research staff then worked with the prior approval unit at Healthcare and Family Services to make sure the medication would be covered when the family went to the pharmacy.

The prior approval was successful and the family got the medication their child needed to prevent hospitalization.