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Contributor

insurance companies determining treatments and medication choices is no favor

I was not particularly surprised to see the increases in monthly premiums for the AARP sponsored health insurance packages, but I was disgusted to receive my 'personalized' notice that my medications were no longer going to be covered as in the past.  What is it that has inured us to insurance companies deciding what is and is not acceptable treatment or medication based on their ability/inability to make a profitable deal with drug companies?  The company was kind enough to send me their recommended alternatives, both of which I tried and both of which created unacceptable side effects.  I suppose that is nothing compared to the consideration of corporate profits.  I consider my doctor to be the one to provide the best alternatives in treatment for health issues.  We're long past due to complain long and loud until this practice by insurance companies is halted.

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Bronze Conversationalist

@unlistedmoniker sounds like you have a managed care plan (Advantage PPO, HMO, etc). In those situations the carrier, not your provider, determine what level of care is appropriate or not.

 

Neither you nor your doctor get to decide your care, that responsibility is delegated to your carrier.

 

This is not limited to Rx, but every facet of your care. This includes diagnostic testing and procedures.

 

You and your doctor have a right to appeal the carriers decision. The process is outlined in your policy.

 

FWIW folks on original Medicare don't have to put up with this. With Medicare there is no pre-approval for treatment or testing.


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Periodic Contributor

My husband and I have the same problem on Medicare drug plan F by AARPUnitedHealth Care..  Long stable medications, medications that are in the insurers' plan,  that have been working well suddenly are refused by the insurer, the suggested alternatives then do not work as well but the co-pays are increased massively (recent ones over 4x the one he was taking).  This non-medical switching is becoming a massive problem and forcing some of us to either stop taking a medication or reducing the amount we take to reduce the cost, even though we know we should not be doing that.

 

 

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Bronze Conversationalist

@RKSK359581 you have a Medicare supplement plan F, not drug plan F. There is no such thing.

 

The PBM has more of an impact on formulary med's than your carrier. The PBM determines which are on the formulary, which are not, and the tier level.

 

Also as newer (generic) drugs come available the brand name they replaced rolls off the formulary. Or is stays on the formulary but shifts to a higher tier.

 

Your pharmacist can make suggestions to be reviewed by your PCP.


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Honored Social Butterfly

I will try to explain how the Medicare Part D plans work (Medicare Prescription Drug Coverage).

 

These type plans can be purchased as free-standing plans OR they can be within some Medicare Advantage plans.  Either way, these plans should be evaluated by the beneficiary each year based on your individual needs during open enrollment.  Medications change for the beneficiary as well as on the insurers formulary.

 

The Medicare Part D insurers must cover a select number of medication in each drug classification and in (5) classes they have to cover ALL of them.   Each year they develop their formulary (list of the drugs they cover) including assignment of the tiers (price level) of the drugs.

They also assign any special circumstances to certain drugs for safety or cost control reasons like Quantity Limits, Step Therapy, Prior Approval and list these on their formulary. 

Medicare.gov - What Medicare Part D drug plans cover 

 

If one insurer doesn't cover what medication you need - as long as it is approved for seniors - another plan should probably have it in their formulary.  Shop your plan during open enrollment

(October 15 – December 7, 2020).

 

That's why they are making suggestions to you (and your doctor), i.e. we aren't covering this med that you take but we are covering this other one that may suit your needs.  There may be other circumstances why medications change even during the year - a drug that enters the generic market, a drug that is removed because of an FDA ruling,

 

If you and your doc are sold on one particular med, check other insurers in your area and change plans before open enrollment ends.  You also have the right to file an appeal or ask for an exception.

Medicare.gov - Medicare prescription drug coverage appeals

 

Sometimes even NOT using the insurance coverage can give you a better (cash) price using places like Costco or GoodRx.

 

 

 

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Periodic Contributor

Our insurer covered the drug my husband is taking, and it is was still in their formulary for this year.  Received the letter saying the drug would no longer be covered just after the sign-up period closed.  Only reason appears to be that they can increase the co-pays to over 4x the cost on the new drug recommendations.

Trying to use Costco or GoodRx or another such plan does not work, because those who are on Medicare plans are excluded from doing so. Read the terms!

 

 

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Bronze Conversationalist

@RKSK359581 as stated earlier, the carrier PBM dictates the formulary and tier.

 

Costco participates in many drug plans and also accepts cash.

 

GoodRx is only for generics.

 

Both Costco and GoodRx will fill your prescriptions and Medicare can't do a thing about it. GoodRx is a discount card and you are not allowed to file the claim with your PDP + use the discount card.

 

Ask your pharmacy to explain.


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Periodic Contributor

The insurers and government are looking at short term pennies in doing this non-medical switching, but are ignoring the long-term costs that come from requiring the use of ineffective or harmful drugs rather than allowing doctors to monitor patient responses to medications and choosing the best for the patient.

 

 

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Honored Social Butterfly

@RKSK359581 

You can take any medication your doctor prescribes - now whether or not the insurer pays for it is another matter or paying the same amount for it as when you 1st signed up.  Insurers have price increases too; they give alternative if the old med jumps up in price and Tier.  This isn't non-medical switching - it is cost efficiency.  Insurance is a share and share alike program - cost efficiencies are part of the program.  Same is true if the insurers begins to add qualifiers like prior authorization, step therapy, quantity limits, etc.

 

Read this link from pages 26 - page 33 and page 78 and it will tell you how you how the program works (pages 26 - 33) and what your options might be (page 78).

 

Medicare.gov - Your Guide to Prescription Drug Coverage 

 

Periodic Contributor

Certainly, what you said is true, but is not the issue.  The issue is non-medical switching by the insurer.  Usually, this switching is done on newer drugs for which there is no generic, and the drugs are higher cost. In our experiences, my husband had tried another similar drug that did not work well, and had been on this drug for several years as it had been extremely effective.  Suddenly he received a letter demanding that he switch to another drug at 4 times the co-pay, and that the drug he was taking would not be covered.  This just after the end of the sign-up period so that we could not switch insurers. Because of this non-medical switching, his first three month fill of his medications have put him in the donut hole.  As seniors on medicare and medigap, plus plan D, our medical costs are now over half our income.

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Honored Social Butterfly

@RKSK359581 

The insurer should not recommend a higher price med - other than a safety issue from the FDA, the only other reason is to suggest a lower price med. when the older one goes up in price or Tier category.   For a safety issue they can completely pull the med from their formulary - otherwise it is just a cost adjustment - for them and the insured.

 

Insurance companies cannot change what you take; only your doctor can do that - but the insurer can make suggestions and make you aware of cost increase or if a generic has come on the market.

Read the Medicare link that I gave you on how Prescription drug coverage works - page 26 - 33 and page 78.

Medicare.gov - Your Guide to Prescription Drug Coverage

Is your insurer deviating from this process? 

Note your possible remedy on page 78.

Talk to the Doctor.

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