Filing Complaint with Medicare on Unethical Part D insurer

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drawpoker
Posts: 2379
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Location: Delmarva

Filing Complaint with Medicare on Unethical Part D insurer

Post by drawpoker » Tue Aug 13, 2019 4:26 pm

Filed my first-ever complaint with Medicare. On my Part D plan (SilverScript). Medicare does make it very easy, file online, limited to 1,500 characters, but that seems adequate. Am wondering if anyone else here has had any success with this (?)

My beef - Oncology doc prescribes Lidocaine/Prilocaine cream Aug. 7. When I call pharmacy to see if it is ready they say, nope, your insurer is requiring prior authorization for this drug, we have contacted your doctor, will let you know when we get decision. Inquired what would be cash price if insurer declines to approve it? $27.

On Monday, Aug 12, I get 2 phone calls, one a robocall from SilverScript stating "prior authorization has been approved and you may fill this prescription at your pharmacy of choice", the second call, from pharmacy saying it is ready.

Go to pharmacy and am told "that will be $36.85 please". WHAT? Pharmacist informs me that insurance is not covering any portion of the cost, there is no co-pay amount, it is all on me. WHAT?

As I wrote in my complaint, why is the insurer allowed to delay things by insisting on prior authorization when they have no intention of treating it as a covered drug? Isn't that deceptive, misleading, and all-around bad faith dealing? Aren't they supposed to be honest and say Sorry, this is not a covered drug in our formulary, your plan does not offer any benefits for this. Deliberately, needlessly, causing a delay of five days for the patient.

Wonder if Medicare will give me any satisfaction. Anyone have any experience with this?

jebmke
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Joined: Thu Apr 05, 2007 2:44 pm

Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by jebmke » Tue Aug 13, 2019 4:41 pm

Given how much variability I have seen in Part D policies I'd guess that Medicare has no role in this. I may be wrong. Insurance is regulated by the state in MD so if I had an issue, that is where I'd go first if I had an issue.
When you discover that you are riding a dead horse, the best strategy is to dismount.

strafe
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Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by strafe » Tue Aug 13, 2019 4:53 pm

What does your EOB say? Are you satisfying a deductible? What is the usual copay for that medication tier?

EMLA cream is often used by dialysis patients, which would be covered by Part B. That could have been the nature of the prior auth — to determine Part B vs Part D.

littlebird
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Location: Valley of the Sun, AZ

Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by littlebird » Tue Aug 13, 2019 4:56 pm

My only experience with a complaint to Medicare was a complete waste of time, although my complaint was about a rehab that withheld liquids and dehydrated my spouse to nearly the point of death. He was revived by emergency EMTs and brought to hospital, where they kept him for 10 days to recover.

Medicare‘s ruling was that according to the rehab’s records, they did everything right. The hospital records, which I know they did obtain, were completely ignored. The problem is, if they put the rehab, which was one of the higher rated ones in the area (although it has since slipped significantly) out of business, who’s going to take in all the patients released from hospitals only days after major surgery, with i.v. tubes, catheters, drains, bandages, immobile, etc.? So it is strongly in Medicare’s interest to not find against a rehab facility. Whether a similar reasoning exists for pharmacy benefit managers or insurance companies, I don’t know. But don’t be surprised if it goes inexplicably against you.

megabad
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Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by megabad » Tue Aug 13, 2019 5:08 pm

drawpoker wrote:
Tue Aug 13, 2019 4:26 pm
Wonder if Medicare will give me any satisfaction. Anyone have any experience with this?
While disfunctional, this seems pretty normal to me with Part D plans. Pre authorization is normal for some drugs and is allowable as far as I know. When you pick up your drug, you would just say, I will pay the cash price instead of the insurance price. It is pretty normal in my experience for insurance to take a while to figure out what is covered and what they will pay. I would call it dysfunctional, not unethical personally. The way I have seen folks alleviate it is by using an associated mail pharmacy. Seems to get approved much faster there and it is usually dramatically cheaper anyway.

Topic Author
drawpoker
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Joined: Mon May 19, 2014 6:33 pm
Location: Delmarva

Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by drawpoker » Tue Aug 13, 2019 5:25 pm

strafe wrote:
Tue Aug 13, 2019 4:53 pm
What does your EOB say?

It (when it is mailed) won't say anything. Since the insurer wasn't covering it, it won't appear.

Are you satisfying a deductible?
No, this is one of the zero-deductible Part D plans.

What is the usual copay for that medication tier?

It isn't on any tier! The insurer is taking the position it is not a covered drug, the patient pays 100%.


EMLA cream is often used by dialysis patients, which would be covered by Part B. That could have been the nature of the prior auth — to determine Part B vs Part D.

Don't think that was it. It was clearly written by an oncologist to be used in connection with a chemoport, applied directly by the patient, not given/administered clinically as with Part B drugs.

BobTexas
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Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by BobTexas » Tue Aug 13, 2019 5:30 pm

drawpoker wrote:
Tue Aug 13, 2019 4:26 pm
Filed my first-ever complaint with Medicare. On my Part D plan (SilverScript). Medicare does make it very easy, file online, limited to 1,500 characters, but that seems adequate. Am wondering if anyone else here has had any success with this (?)

My beef - Oncology doc prescribes Lidocaine/Prilocaine cream Aug. 7. When I call pharmacy to see if it is ready they say, nope, your insurer is requiring prior authorization for this drug, we have contacted your doctor, will let you know when we get decision. Inquired what would be cash price if insurer declines to approve it? $27.

On Monday, Aug 12, I get 2 phone calls, one a robocall from SilverScript stating "prior authorization has been approved and you may fill this prescription at your pharmacy of choice", the second call, from pharmacy saying it is ready.

Go to pharmacy and am told "that will be $36.85 please". WHAT? Pharmacist informs me that insurance is not covering any portion of the cost, there is no co-pay amount, it is all on me. WHAT?

As I wrote in my complaint, why is the insurer allowed to delay things by insisting on prior authorization when they have no intention of treating it as a covered drug? Isn't that deceptive, misleading, and all-around bad faith dealing? Aren't they supposed to be honest and say Sorry, this is not a covered drug in our formulary, your plan does not offer any benefits for this. Deliberately, needlessly, causing a delay of five days for the patient.

Wonder if Medicare will give me any satisfaction. Anyone have any experience with this?
Can you go to Walmart or Costco and pay the cash price? $27? Never mention Medicare. I have a prescription (non-Medicare) where the cash price is much lower then my insurance price at CVS.

cashmoney
Posts: 311
Joined: Thu Jun 29, 2017 11:15 pm

Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by cashmoney » Tue Aug 13, 2019 9:16 pm

drawpoker wrote:
Tue Aug 13, 2019 4:26 pm
Filed my first-ever complaint with Medicare. On my Part D plan (SilverScript). Medicare does make it very easy, file online, limited to 1,500 characters, but that seems adequate. Am wondering if anyone else here has had any success with this (?)

My beef - Oncology doc prescribes Lidocaine/Prilocaine cream Aug. 7. When I call pharmacy to see if it is ready they say, nope, your insurer is requiring prior authorization for this drug, we have contacted your doctor, will let you know when we get decision. Inquired what would be cash price if insurer declines to approve it? $27.

On Monday, Aug 12, I get 2 phone calls, one a robocall from SilverScript stating "prior authorization has been approved and you may fill this prescription at your pharmacy of choice", the second call, from pharmacy saying it is ready.

Go to pharmacy and am told "that will be $36.85 please". WHAT? Pharmacist informs me that insurance is not covering any portion of the cost, there is no co-pay amount, it is all on me. WHAT?

As I wrote in my complaint, why is the insurer allowed to delay things by insisting on prior authorization when they have no intention of treating it as a covered drug? Isn't that deceptive, misleading, and all-around bad faith dealing? Aren't they supposed to be honest and say Sorry, this is not a covered drug in our formulary, your plan does not offer any benefits for this. Deliberately, needlessly, causing a delay of five days for the patient.

Wonder if Medicare will give me any satisfaction. Anyone have any experience with this?

If this was a rx you were taking when you enrolled in Silverscript the agent should have told you there was a prior authorization required for this med when you gave them your list of meds to check and in general going forward made you aware of about possible drug restrictions such as prior authorization,step therapy and quantity limit. Also the plans formulary list that is suppose to be mailed to you should indicate this as well .Based on your co insurance amount and your location you have must have the Silvercripts Plus plan ? If so lidicaine cream at the most common medicare dosage cost Silvercripts about 100.00 and your co pay level for this is tier 4 which is a 40% co insurance so 36.00 co payment sounds about right .( there can be small variances of cost between different pharmacies)

The good news is you can use www.Goodrx.com discount card and buy it for less than 10.00 without insurance .Believe it or not Goodrx can somehow negotiate a price of less than 10.00 for this drug whereas the Silverscripts negotiated price is about 100.00 . Always check Goodrx before using your insurance


I am a licensed health insurance agent

Nowizard
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Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by Nowizard » Tue Aug 13, 2019 9:53 pm

You may have misunderstood. There are numerous cases where the cash cost of a drug is less than you are required to pay with insurance. Yes, it makes no sense, but pharmacists are contracted not to tell that to a patient unless specifically asked. It is always wise to ask the pharmacy what is the insured and cash price before a script is filled. Insurance and pharma are big players, as we know, with medication.

Tim

fauxden
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Joined: Fri Jun 13, 2014 11:15 pm

Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by fauxden » Tue Aug 13, 2019 10:07 pm

I have some expertise in this as I am a pharmacist for a private, independent, pharmacy. These ridiculous scams we call part d plans are orchestrated by what is called a pharmacy benefit manager(and nearly all your rx insurance claims) and they have been screwing people for decades now.

Here is an advocacy page with way more information than you’ll ever want.

https://www.ncpanet.org/advocacy/the-to ... -resources

https://youtu.be/_-75QVQyhsM

richardglm
Posts: 262
Joined: Sun Jan 04, 2015 9:42 pm

Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by richardglm » Wed Aug 14, 2019 12:57 am

I am not sure but if there is a yearly out of pocket maximum it may be less beneficial to pay the cash price if it does not count to an OOP max that you'd hit anyways

cashmoney
Posts: 311
Joined: Thu Jun 29, 2017 11:15 pm

Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by cashmoney » Wed Aug 14, 2019 9:12 am

richardglm wrote:
Wed Aug 14, 2019 12:57 am
I am not sure but if there is a yearly out of pocket maximum it may be less beneficial to pay the cash price if it does not count to an OOP max that you'd hit anyways



No MOOP on part D.There is however a concern that you could exhaust their Initial coverage of 3820.00 putting you in the gap so another benefits of using Goodrx or any other discount rx plan when available is these amounts don't count against your Initial Coverage.Be careful though because sometimes a pharmacy will give you the Goodrx price but will still file to insurance for greater reimbursement vs Goodrx therefore still using up your Initial Coverage.If pharmacy doesn't cooperate use a different pharmacy that doesn't have your insurance on file to get the cash/coupon/Goodrx price.

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FIREchief
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Re: Filing Complaint with Medicare on Unethical Part D insurer

Post by FIREchief » Wed Aug 14, 2019 2:31 pm

fauxden wrote:
Tue Aug 13, 2019 10:07 pm
I have some expertise in this as I am a pharmacist for a private, independent, pharmacy. These ridiculous scams we call part d plans are orchestrated by what is called a pharmacy benefit manager(and nearly all your rx insurance claims) and they have been screwing people for decades now.

Here is an advocacy page with way more information than you’ll ever want.

https://www.ncpanet.org/advocacy/the-to ... -resources

https://youtu.be/_-75QVQyhsM
Thank you for providing this informed input. I'm not to Medicare age yet, but have started trying to understand the options. DW and I take a number of medications, but even now they are cheaper to just buy out of pocket than to use our prescription drug coverage. I'm even leaning towards a Medicare Advantage plan w/drug coverage at 65 instead of a Medigap plus Part D combo, partly because of what I've been able to learn about Part D plans.
I am not a lawyer, accountant or financial advisor. Any advice or suggestions that I may provide shall be considered for entertainment purposes only.

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