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Health insurance case study: Solving a medication crisis in the Caymans

A 15-year-old with cystic fibrosis gains access to high-cost, limited availability new drug in her Caribbean home

This is the story of Sophie and Karen* and how Aetna International’s CARE team helped navigate a complex situation to gain access to high-cost medication in their home abroad. Read their story to see how our members benefit from the expertise and support of our CARE team.

Catastrophe

Sophie is a 15-year-old American girl living in the Cayman Islands with her family. Sophie has cystic fibrosis, a ‘catastrophic’ condition which affects the lungs as well as other internal organs. Symptoms usually include difficulty breathing, excess mucus and frequent chest infections among many others.  

The term ‘catastrophic’ refers to illnesses that are usually life-threatening, often entailing significant disability. Such conditions usually require lengthy hospitalisation with expensive therapies and treatments. Diagnoses of this nature and the high cost of drugs have the power to deplete even wealthy families’ financial resources unless covered by specialist medical insurance policies.

While no cures for cystic fibrosis are known, several treatment methods are used.

Switching medication

Aetna International members since 2014, Sophie’s mum Karen got in touch with us in October 2018 to request switching Sophie to a new leading-edge medication, Symdeko, to treat her condition. The Americas CARE team Clinical Team Lead, Mary, picked up the call.

Meet Mary

Mary, a Registered Nurse Clinical Team Lead certified in managed care nursing, has been with Aetna for 11 years. Mary currently supports our customers and members by providing a vast array of services such as Utilisation Management (preauthorisation and concurrent review) and Case Management (condition management, pre-trip planning).  Her nursing background also includes long-term care, skilled nursing, and paediatric nursing.

When Mary received the call from Karen, she worked with Sophie’s treating physician to determine that it was in the best interest of Sophie’s health to obtain this drug and helped ensure that it was suitable for Sophie to transition to this medication. However, we discovered that the medication was not only far more difficult to acquire in Cayman but also at a much higher cost than if obtained in the U.S..

The drug’s manufacturer had confined its distribution to a limited number of specific pharmacies — none of which were in the Cayman Islands. Therefore, it would increase the cost by 170% to $59,528 for a month’s supply to be specially delivered to Cayman. This would negatively impact the member’s finances, something we were keen to help avoid.

Plan B

With the limited availability of Sophie’s drug nearby, Aetna International worked with its partners to come up with a plan to help.

At this time, Sophie and her mother were flying to the U.S. every three months for a check-up with a specialist. Therefore, she suggested if they could pick up the medication from the pharmacy near the doctor’s office.

Mary welcomed the idea and was willing to assist in obtaining the approval for the medication. However, after further research, she realised the pharmacy was out of network which would mean the member would still incur a higher cost. Mary, and with the help of Aetna’s pharmacy team, was able to locate a specialty pharmacy in the U.S., within Aetna’s network, and that was on the distribution list for the medication.

Knowing the member was very overwhelmed at this stage, Mary made herself the single point of contact for her, until the issue was resolved. This meant keeping in touch with the member with regular updates on how the situation was being resolved and providing simple steps for the member to follow to obtain the medication.

Initially, the plan was for Sophie and Karen to pick up three months’ worth of medication on each U.S. trip. But Sophie didn’t have enough medication to see her through to her upcoming American appointment. She needed the drugs sooner. The situation needed to be managed to avoid it becoming a medical emergency.

Mum Karen happened to be flying to Washington D.C. on a personal trip in the immediate future. Karen suggested that she could fly to the pharmacy in Boston to pick up the medication. To save Karen going to such lengths, Mary arranged to have the medication sent to a specialty pharmacy in DC. This not only helped the member avoid incurring extra travel expense, it helped ensure the medication could be obtained via an in-network pharmacy, thereby also helping to keep costs in check for the member.

Further complications

The night before flying to the U.S., Karen called Mary in tears. Earlier in the day, she had called the pharmacy in the U.S. who told her she would have to pay 20 percent of the drug cost up front due to the high value of the drugs.

Mary quickly worked behind the scenes to resolve the issue. Health insurance can be complicated, with differences in co-insurance limits, co-payments and deductibles affecting aspects of cover. Mary quickly straightened out the crossed wires and resolved the issues the same day. Karen resubmitted the request to the pharmacy who confirmed that there was no obligation to pay anything up front.

The best health outcomes

The plan worked well. Karen picked up the medication and flew home to Sophie. The potential medical emergency was averted, and Sophie continues to get her medication every three months at her U.S. appointments. Mary continues to be on hand to monitor and support Sophie’s health care needs, supporting the treatment plan to address the underlying causes of the disease and help Sophie manage her symptoms.

With their flexible, collaborative approach, Aetna’s expert CARE team helped the family overcome the challenges presented by living away from home so Sophie could successfully transition from one medication to another. By adopting value-based care initiatives, which focus on health outcomes and a better care experience and treatment pathway for people, we help ensure our members can access quality care and service, whether in a preventative, chronic or acute capacity.

Expats and medication

International travel and relocation involve a lot of organisation, from plane tickets and packing to accommodation and international private medical insurance. One important aspect of international travel to consider — and especially relocation — is medication.

Whether you’re managing a chronic disease, such as diabetes, or a condition such as anxiety, ensuring that you’re sticking to your medication plan is crucial to your overall health and well-being.

In the throes of booking and planning, many people forget to check whether they have enough medication to cover their trip or initial settling-in period, whether they can access a given drug in their destination and even whether it’s legal there.

How we can help

The Aetna International Care and Response Excellence (CARE) team offers a round-the-clock service to help members get the care support solutions they need in a range of different situations — from pre-trip planning and medical emergencies to finding the right health care provider and accessing prescribed medication.

Whether you’re a globally mobile individual, are relocating to another country or are planning a holiday, the CARE team will be able to help you with all your medication needs, including:

  • Helping you get an adequate supply for your trip and/or settling-in period
  • Finding doctors, specialists, hospitals and accessing medication in your destination country
  • Defining whether medication is available and/or legal in your destination country
  • Identifying alternative brands of medication
  • What to do in the event of a medication emergency, when you run out or lose your supply
  • Shipping medication to your destination, if necessary
  • Providing advice around vaccinations and prophylactic medication
  • Ensuring your whole family is catered to, plan cover permitting.

While these services are particularly useful to those moving abroad, they can be used by expats at any time to help you stay happy, healthy and productive in your new home.

For more information about the CARE team and the other benefits and services available through your plan, login to (or register for) the Health Hub.

Are you an employer?

Find out more about how Aetna International’s CARE team can help you support your international employees and help to keep them healthy, happy, safe and productive.

*Name changed to protect the identity of the members

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