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Old 05-14-2015, 05:11 PM   #15
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Denial on initial request seems to be becoming the norm with the medicare HMO/PPO insurers. I am taking a pill that is almost $4000.00/month, and my copay is over $900/month. I can understand the insurer wanting full documentation before they grant approval - after all, it's the government's money they're spending. In my case my oncologist handled the approval process - just took a few extra days to get the medicine!!
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Old 05-14-2015, 07:47 PM   #16
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Denial on initial request seems to be becoming the norm with the medicare HMO/PPO insurers.
Aren't these HMO/PPO plans actually Medicare Advantage rather than regular Part D? IMHO it's very confusing to mix the two in a thread since they are very different animals.
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Old 05-14-2015, 10:08 PM   #17
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You do realize that the OP is talking about MediCare, right? As are most of the replies? And that this has absolutely nothing to do with the ACA?
Not quite true. The ACA does impact and make changes to Medicare. It has regulatory control over providers. The only difference is, that Medicare recipients do not participate in the Health Insurance Marketplace.
This is not to say that this fact is in itself detrimental, but it could have impact on individual subscribers.
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Old 05-14-2015, 10:31 PM   #18
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I'm not sure how the HMO/PPOs work, our problem is just with the Medicare Part D Prescription plan. They are probably all working about the same though since Medicare is involved, and you know who has authorized the removal of $700 billion from Medicare over the next decade to pay for health insurance for those who won't pay for it themselves.

The government seems to think this is their money but somewhere along the line someone seems to have forgotten that this is our money that all of us have paid into Medicare all our working lives. Now we're just wanting some of it back.

I thought our problem was with an expensive drug at $253/month and costs us only $42/month but it pales with the $4,000/month. Makes me feel kind of bad for even complaining about the denial. I guess what aggravated me the most was back in November I had to change plans within the same company in order to get the wife's drug covered, it tripled our monthly premium then to be required for them to authorize it. If they didn't want to cover it that should be disclosed up front, not in some fine print someplace I was told I missed.

Hope we're not getting too much off the subject here and into the political arena. All of us need help at one time or another with our heath care insurance problems. This has been our first and glad to know we're not the only ones.
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Old 05-15-2015, 04:56 AM   #19
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Somebody really needs to make some changes as to how drug companies treat their customers. The are much more interested in profits than patients.
It ain't the drug companies, it is the new healthcare system run by the d*mn government. The drug companies are at the mercy of government regulations and bureaucrats. MediCare included.

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Old 05-15-2015, 05:08 AM   #20
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Same thing is happening to just regular insurance plan, the past two years for me.
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Old 05-15-2015, 08:55 PM   #21
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If they didn't want to cover it that should be disclosed up front, not in some fine print someplace I was told I missed.
All the Part D plans we investigated had online listings of the medications they would cover and the copays that would be required for each. The insurance agency we worked with had an online calculator that allowed us to model the costs of our specific prescriptions with each of the carriers we were considering. There was no mystery and no fine print that we failed to read.
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Old 05-15-2015, 11:42 PM   #22
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That's what the mystery is for me, after knowing which drugs our company would/would not cover from their web site where was the fine print the company kept telling us was there requiring "Prior Authorization" for certain of their covered drugs. I always thought drugs would either be covered or they wouldn't.
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Old 05-16-2015, 07:12 AM   #23
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That's what the mystery is for me, after knowing which drugs our company would/would not cover from their web site where was the fine print the company kept telling us was there requiring "Prior Authorization" for certain of their covered drugs. I always thought drugs would either be covered or they wouldn't.
I suspect that the list of drugs that require pre-authorization is also available if you ask for it or search. For example, here is the pre-authorization list for Cigna's Part D plan which is what we happen to have: http://www.cigna.com/iwov-resources/...dicare%20Plans
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Old 05-16-2015, 04:35 PM   #24
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Drug companies have a list of prescription drugs they cover at minimal co-pay and generally are the generic equivalent of branded drugs... it's called a formulary. The co-pay is higher on the branded drugs if there is a generic equivalent. Drugs that are NOT on the formulary must be pre-approved.

HMO/PPO plans are still Medicare, but the insurance companies contract with the government (Medicare) to administer the program, handle the paperwork, etc. The idea is that they can more effectively administer the program than Washington can, and they are paid a percentage of what they can save the program. This leads to occasional denials, pre-approvals, questions, limited choices of physicians, etc. Physicians that are part of the "Network" agree to accept whatever payment the HMO deems proper. Physicians not in the network can bill you for the difference. Either way - HMO/PPO or traditional medicare - you still must face the coverage gap (doughnut hole!) before you get full coverage.

I can't complain. So far my total expenses have been over a half-million dollars, and my out of pocket expenses have been less than $15K. My HMO premiums are less than traditional medicare plus a plan F supplement, but there is a co-pay every time I walk into a doctor's office!!😏
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