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Old 05-06-2015, 09:38 PM   #1
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Part "D" prescription renewal shock

Just got a terrible shock this week when we tried to fill one of my wife's prescriptions. I switched plans within the same company back in November, which more than tripled our monthly premium, so her drug would be covered since it was deleted from the plan we'd been in for several years.
Seems somewhere along the line they claim I missed the point that even though the drug is covered it still has to have "Prior Authorization" from the company before it can be filled. And that has all sorts of hoops to jump through in order to get that drug filled. First attempt for the Authorization was denied, so right now we're trying the Appeal but that doesn't look very good either. This is about a $180/month drug that had been costing us $42/month when it was covered so is going to be a pretty big hit unless we and our doctor can come up with a replacement.

Main reason for this Post is to warn anyone with a Part D prescription plan covering expensive drugs to be sure and watch for the fine print declaring "Prior Authorization" is required. And from what our doctor has initially told us, that Authorization is denied more times than approved. Looks like this is just another scam by the prescription companies to stick it to the consumer, increased premiums without any increase in coverage.
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Old 05-06-2015, 09:52 PM   #2
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Quote:
Originally Posted by wagonmaster2 View Post
Just got a terrible shock this week when we tried to fill one of my wife's prescriptions. I switched plans within the same company back in November, which more than tripled our monthly premium, so her drug would be covered since it was deleted from the plan we'd been in for several years.
Seems somewhere along the line they claim I missed the point that even though the drug is covered it still has to have "Prior Authorization" from the company before it can be filled. And that has all sorts of hoops to jump through in order to get that drug filled. First attempt for the Authorization was denied, so right now we're trying the Appeal but that doesn't look very good either. This is about a $180/month drug that had been costing us $42/month when it was covered so is going to be a pretty big hit unless we and our doctor can come up with a replacement.

Main reason for this Post is to warn anyone with a Part D prescription plan covering expensive drugs to be sure and watch for the fine print declaring "Prior Authorization" is required. And from what our doctor has initially told us, that Authorization is denied more times than approved. Looks like this is just another scam by the prescription companies to stick it to the consumer, increased premiums without any increase in coverage.
You should go on the Medicare website every November or early December and compare coverages. I have changed Part D carriers every year since enrolling. The coverages change from year to year even with the same carrier. Also a really big thing is the pharmacy you use for filling the prescriptions. CVS has been the least costly of any of the national chains, even Walmart.
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Old 05-06-2015, 11:31 PM   #3
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That's exactly what I do each October, and why I had to change plans. I discovered my old plan wasn't going to cover her main prescription in 2015 but their premium plan did, so I changed. Just because the Medicare.gov web site says a company does cover a certain drug doesn't necessarily mean you will be in good shape when new/renewals come up if there is a notation someplace that it requires the "Prior Authorization". This is just a sneaky way for the company to hook you for the whole next year, increase your premium, and still not have to pay the cost above your co-pay.
Just be aware, they can s___w you without a kiss. I'll certainly be looking for this the end of this year and not get took for a ride again.
Our doctor said they have another patient with the same situation.
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Old 05-07-2015, 07:24 AM   #4
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Welcome to our wonderful new world of healthcare, thanks to....well you know who.
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Old 05-07-2015, 07:31 AM   #5
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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.

Case in point, my insulin was costing my $800 every 3 months. Part D covered all but $40 of that for the first 6 months. That then put my into my donut hold after 6 months. I now go to VA and get my meds with an $8 copay for 3 month prescription.

There is no generic although that same insulin has been in production for a lot of years. There is really nothing us little people can do about it though.

OK, I'll get off my soapbox now. Good luck
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Old 05-07-2015, 09:12 AM   #6
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Switch to an Advantage Plan. Read part C in your medicare book. Drug coverage is included.

My wife and I both have a Blue Cross Advantage Plan. We pay nothing and each of us have $6 a month refunded to our monthly SS benefit.
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Old 05-07-2015, 10:10 AM   #7
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Quote:
Originally Posted by wagonmaster2 View Post
Just got a terrible shock this week when we tried to fill one of my wife's prescriptions. I switched plans within the same company back in November, which more than tripled our monthly premium, so her drug would be covered since it was deleted from the plan we'd been in for several years.
Seems somewhere along the line they claim I missed the point that even though the drug is covered it still has to have "Prior Authorization" from the company before it can be filled. And that has all sorts of hoops to jump through in order to get that drug filled. First attempt for the Authorization was denied, so right now we're trying the Appeal but that doesn't look very good either. This is about a $180/month drug that had been costing us $42/month when it was covered so is going to be a pretty big hit unless we and our doctor can come up with a replacement.

Main reason for this Post is to warn anyone with a Part D prescription plan covering expensive drugs to be sure and watch for the fine print declaring "Prior Authorization" is required. And from what our doctor has initially told us, that Authorization is denied more times than approved. Looks like this is just another scam by the prescription companies to stick it to the consumer, increased premiums without any increase in coverage.

My wife has gone through the same thing! I think all the companies are going to the "prior authorization" thing as a means of not paying what they should!

We have found that persistence pays off! She has spent hours on the phone with the insurance companies, arguing with them that the particular drug is the only one in it's class that she is able to take without side effects and that is effective for her problem. If the person you're talking to refuses to approve it, insist on talking to their supervisor! So far, she has been able to get them to approve them! The key is not to give up, just keep bugging them until they approve it!

Good luck, happy trails, and God bless!
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Old 05-07-2015, 10:28 AM   #8
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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.

Case in point, my insulin was costing my $800 every 3 months. Part D covered all but $40 of that for the first 6 months. That then put my into my donut hold after 6 months. I now go to VA and get my meds with an $8 copay for 3 month prescription.

There is no generic although that same insulin has been in production for a lot of years. There is really nothing us little people can do about it though.

OK, I'll get off my soapbox now. Good luck
The donut hole issue has absolutely nothing to do with the insurance companies and is entirely the result of how Congress set up the legislation that established Part D. There are a lot of things you can blame insurance companies for but this isn't one of them.

Nor can you blame an insurance company for its $40 copay for a medication compared to VA's copay since those copays are published at the Medicare Open Season time each year and you can use that information to decide which plan is the best for you. Some have higher copays and lower premiums and others have lower copays and higher premiums. It's your choice.
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Old 05-07-2015, 08:02 PM   #9
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If I were to write what I think of this entire health care program I would be barred from IRV2 for life.
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Old 05-07-2015, 08:54 PM   #10
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If I were to write what I think of this entire health care program I would be barred from IRV2 for life.
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?
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Old 05-07-2015, 08:56 PM   #11
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Welcome to our wonderful new world of healthcare, thanks to....well you know who.
This thread is about Medicare prescription coverage, not ACA. And there have been no significant changes (that I know of) in Medicare regarding prescription drugs since the ACA went into effect.
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Old 05-07-2015, 09:32 PM   #12
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Update: Yesterday our doctor's office went through the Appeal process that was stipulated in the Denial of our Authorization request. This afternoon we got a telephone call from a very nice lady with our Part D insurance company and was told our Appeal was okayed. So now we have the prescription being filled and paid for by the insurance company (at least everything but our copay).

Just like Joe in post #7 stated, don't give up and keep bugging them. Undoubtedly the standard operating procedure must be to always deny the first request for the Authorization. During the first request both the lady our doctor's assistant talked to and the different one I talked to the next day was like what I would expect from the IRS. Listen to what I'm saying, don't talk while I'm interupting, do what i say, and quit talking when I start talking. But during the appeal process I talked to two different ladys who were just as nice and polite as a person could ever expect, gave precise information on how to appeal, and all the phone/fax numbers needed to do it.

Hope this information will help and be some support for anyone facing this same unfortunate disagreeable situation.

When the person said "it's the squeaky wheel that gets the grease" they must have been going through something like this and really hit the nail on the head.
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Old 05-14-2015, 04:43 PM   #13
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Update: Yesterday our doctor's office went through the Appeal process that was stipulated in the Denial of our Authorization request. This afternoon we got a telephone call from a very nice lady with our Part D insurance company and was told our Appeal was okayed. So now we have the prescription being filled and paid for by the insurance company (at least everything but our copay).

Just like Joe in post #7 stated, don't give up and keep bugging them. Undoubtedly the standard operating procedure must be to always deny the first request for the Authorization. During the first request both the lady our doctor's assistant talked to and the different one I talked to the next day was like what I would expect from the IRS. Listen to what I'm saying, don't talk while I'm interupting, do what i say, and quit talking when I start talking. But during the appeal process I talked to two different ladys who were just as nice and polite as a person could ever expect, gave precise information on how to appeal, and all the phone/fax numbers needed to do it.

Hope this information will help and be some support for anyone facing this same unfortunate disagreeable situation.

When the person said "it's the squeaky wheel that gets the grease" they must have been going through something like this and really hit the nail on the head.

Great news! Yep, they don't like that continuous squeaking, it gets on their nerves!
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Old 05-14-2015, 04:56 PM   #14
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Welcome to our wonderful new world of healthcare, thanks to....well you know who.
X2 we need a leader that works for us that worked our entire lives to pay into a healthcare system that would cover us when we retired. Now that we are retired, it is no longer there or on a "limited" coverage basis. How sad.
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