Is there an advocate for seniors when they are dealing with insurance companies?
I went on United Healthcare Secure Horizons insurance plan this year and they refuse to cover my insulin prescriptions without having to call them every month after they turn down my prescriptions.
I still haven't gotten any insulin this month. Last month they turned down my prescription and I had to call them to get it resolved, or so I thought. This month again they turned down my prescription for insulin. I am down to getting samples from my local diabetes dept. so I can continue living.
This is the company that AARP backs. When I call them they tell me to have my diabetes dept. call them because the prescriptions have to be preapproved. When they called they were told that the prescriptions don't have to be preapproved. Still I don't get the medications I need to live. Maybe AARP should look for someone else to push on us.
UHC Secure Horizons is an MA plan. Each carrier set's their own rules, preferred pharmacy's, copay's, etc. Your agent should compare plans for you each year during open enrollment. The plan you have this year may not work as well for you next year.
Some carriers own an in house mail order pharmacy, some do not. Carriers that own the pharmacy usually have better prices (copay's) than those that rent a mail pharmacy.
If the agent you used misled you about your benefits you may have recourse through Medicare. Otherwise, you are stuck with your plan until the next open enrollment.
I contacted the California Insurance Commision and they told me under law I can revert back to my previous plan at any time this year even though United Healthcare said I could not. They thought that the policy of only dealing only with online pharnacies for diabetic supplies and then urging people to use their online pharmacy was something the Department of Medicare Services might be interested in hearing about since it sounded kind of immoral. I finally got my insulin for this month but if I continue to have problems I plan to pursue my other options.
According to the Cal Insurance Commision it is rule #10192.12.
Well here it is but it is nothing more than the guaranteed issue rights in CA under a MEDICARE SUPPLEMENTARY plan (Medigap) - It does NOT apply to a Medicare Advantage plan with a Prescription Drug Program within it. Which I assume your UHC Secure Horizon plan is - MAPD -
(Medicare Advantage with a Prescription Drug Plan).
Maybe the CA Dept of Insurance misunderstood what coverage you have now and what you would like to do. Other MAPD plans might be the same.
10192.12: (a) (1) With respect to the guaranteed issue of a Medicare supplement policy, eligible persons are those individuals described in subdivision (b) who seek to enroll under the policy during the period specified in subdivision (c), and who submit evidence of the date of termination or disenrollment or enrollment in Medicare Part D with the application for a Medicare supplement policy.
You can read the rest (long) but this code does not seem to apply to the coverage you have now - Medigap and Medicare Advantage are (2) different breeds of Medicare coverage. They cover the same things but in a different way.
When the Libre system was 1st approved for Medicare in 2018, it wasn't approved for retail pharmacy disbursement or reimbursement - most likely that is because it is within the Part D part of the program and it does require an Rx.. It may not still be available because it has to come from certain Medical Suppliers. Your (Part D part of your) plan may order from them.
Sorry you are having problems but it does sound more like you are just having difficulty interpreting the plan and how it works. I believe, both of the items you mentioned - the insulin and the Freestyle Libre products would be covered under the MAPD under the Prescription Drug Plan. Check this part of your coverage and it should enumerate any type of pre-approval or other stipulations for these items.
Who picked this plan for you? It may well be for your benefit - you are the best judge based on your health and medicine needs. Buying from their online pharmacy maybe the best option pricewise and availability and if that is the only place they cover it, you do have to go by their rules for these things.
Just review your plan (Evidence of Coverage) and try to come to an understanding about how these things are covered - do not go without - plan your schedule accordingly. Your Doc does not know the intricacies of all the plans, you will have to educate him/her and they should work with you on getting in the approvals if that is what is necessary. That may mean informing the Doc's office of how they communicate with your Prescription Drug plan so nothing falls between the cracks.
These Medicare publication with general info may help you understand this type of coverage a bit better.
I will try that. I also want to find out if it is legal to make certain cockamaimy rules like they do. For example my diabetic provider prescribed Freestyle Libre products to help me monitor my blood sugars. I found out that United Healthcare only covers them if they are aquired through an online pharmacy.
They told me I would have a lot less problems if I purchased all my prescriptions through the United Healthcare owned online pharmacy. Sounds like a scam to me.
Bizman, the use of on-line pharmacies is pretty common for health insurance policies... my former employer's insurance (Aetna) required this, and now my Blue Cross plan on top of Medicare requires that as well. In both cases I could get some items at local pharmacies, but for "long term" needs they really wanted me to use their... call them "mail order" pharmacy. And this is okay, it's one way to keep costs down for everyone!