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Insurance Carrier: Humana
State: South Dakota

Consumer Complaint:

Humana Medicare Part D (drug) Insurance has refused to provide the drug Januvia prescribed by my doctor for Type II Diabetes. How can they practice medicine without a license? I have appealed their decision and am in the process of requesting a review by MAXIMUS the center for Medicare and Medicaid Services contractor. What else can I do? This is the second time they have screwed me over. The last time they directed my pharmacy to provide me with generic diltiazem without my knowledge or permission and I went into Atrial Fibrillation.


Insurance Expert Answer:

Although I am very sympathetic to the complaint (been there), let's face it, they are NOT practicing medicine without a license. They ARE saying "we didn't agree to cover it and we won't pay for it." You are perfectly free to take the prescription and pay what I would bet is an outrageously high price for a drug that is possibly no more than marginally beneficial than a lower cost generic. We have a major national problem in health care costs. Doctors prescribe based on a combination of (1) their own professional judgment (which is based on the literature they read, [including the ads], what their colleagues tell them, and what big Pharma's drug reps tell them, AND (2) the patient's ability to pay for the drug as giving you a prescription for the best medicine would be meaningless if you could not afford it. Most drug plans have formularies -- drugs they cover without question and pay for in full or almost in full. To get drugs not on the formulary, some plans have requirements that the patient go thru the less costly drugs first and only if nothing else works well will they cover the more expensive drugs. Other plans pay only a small part (often about what they typically would have paid for the drug on the formulary).