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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.


Bark less. Wag more.
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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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