This is the ongoing story of how the greedy medical/ prescription [drug] insurance companies prey on us older retired people, who, they presume, won’t fight back but will just lie down and get steam rolled by them. This is my story, my experience, so I am here to tell you that it is true and I tell it to you now.
“What do you mean I can’t have my kidney stone medicine (ABC), a relatively new and therefore expensive prescription drug) anymore and you’re switching me to an old drug, (XYZ), that is much cheaper and on your preferred list). I’ve been on ABC for several years now and it is working very well for me. You are not doctors! You are bean counters, desk jockeys, accountants and CPAs. You have no right and no authority to challenge or change my prescribed medication. Before I joined your prescription drug plan I checked out with you that my drug prescriptions were covered and available to me. Last fall your representative guaranteed me that they were. Now that I am in your system you deny me.”
How many of us senior citizens have found ourselves in this predicament? More specifically, I’m referring to those of us retired people who are on Medicare and must contract with a prescription drug company for a plan to help cover our monthly maintenance drugs. This is known as Medicare part D supplemental insurance. These companies are known as pharmacy benefit managers, or PBMs. Their more common names are Express Scripts and CVS Caremark, for example. There are many, many more of them, perhaps hundreds. I take great care to differentiate these PBMs from the Medicare supplemental insurances like AARP, Anthem, Humana, Aetna and a host of others who we contract with to help cover the expenses that Medicare doesn’t. They are most often not related to the PBMs. In fact, according to USA Today, Anthem is currently suing Express Scripts for damages. Medicare is closely monitoring many other PBMs, and has placed some, like Alpha-Beta Health RX (My former Pharmacy provider) under sanctions for mistreating their customers. Since there are hundreds of these supplemental drug programs out there, maybe thousands, which ones are the good ones and which are to be avoided. What are the criteria?
The back story is as follows. I retired from the Ohio Public Employees Retirement System, OPERS, a few years ago. At that time, we were automatically enrolled in their health insurance system under Humana and a corresponding Part D supplemental Rx insurance (Express Scripts). This system worked reasonably well. Yes, the supplemental Rx program had its preferred, or “Formulary” drugs that they could supply at a very reasonable rate and other drugs that weren’t on their preferred list had to be “overridden” by your doctor and would necessarily cost us a bit more. This I came to understand. When this happened we called the doctor and got the necessary override and things went on fairly smoothly—not perfectly, certainly–but issues seemed to be resolved with a minimum of client upset.
For 2016 we OPERS retired people were notified that now we would have to contract individually for our Medicare supplemental insurance. OPERS would no longer supply or orchestrate our medical insurance. OPERS was, in essence, getting out of the medical insurance business and placing the burden on us. To be fair to us, they contracted with a large firm—One Exchange– to help each of us find comparable coverage and OPERS also agreed to supply additional monetary coverage to help this all happen. Let me be clear that I am not blaming OPERS for what they felt they had to do. But I would surely tell you that this move created great apprehension, massive consternation and ultimately chaos for many of us. Suffice to say, it greatly complicated the lives of those of us in the OPERS Retirement system.
For the year previous to the big move, all of us OPERS retired folks were subjected to countless workshops, notes and e-mails outlining to us what we had to do. I went to a few of these and read all the e-mails. I would tell you that most of us sitting in the audience had little to no experience assessing the various insurances available or really understanding the situation. This insurance was always previously selected and handled by the employers we worked for, or the retirement systems we retired under. Neither did we have any idea of the scope of our decisions despite attending various lectures. In essence, it was like asking us to assess and pick a new rocket propulsion system for the next NASA trip to Mars. OPERS hired a firm—One Exchange– to help us decide and make the transition to new insurance. We were all assured that One Exchange would be looking out for our best interest and help us make the best decisions. Right!!! And if you believe that, they would also like to sell you a bridge in Brooklyn………. Whenever someone tries to assure me of anything at all, I have learned to become suspicious.
My experience with One Exchange went like this: On a specified day in October at a specific time I was required to call them and hear my options and be helped to pick the very best insurance for me. “Required to call them at a specific time”…, is this a red flag or what? If I called at a different time than designated, I would not be able to speak with them as they were so busy. In that event I would be given a time weeks or months later. What actually followed was that I was connected to a person who frankly didn’t have great command of the English language, who was not the least bit empathetic, and clearly did not hear or take into consideration my expressed needs that I repeated several times to her. Ultimately she placed me—that’s right, placed me, not by my choice– in what seemed to me to be an inferior supplemental insurance compared to what OPERS had previously provided. She ignored my input. This choice contradicted what we were advised to pick in the various lectures. She said that the previous advice was not right for me. It seemed as though I had no recourse. According to her judgement, this was the best choice for me, I was assured. Of course I was not assured and next day began gathering information on these supplemental insurance policies and talking with other OPERS retired people. They had similar experiences with One Exchange and were very skeptical and dismayed as well. The general feeling was that we were lumped into a specific insurance company simply to fill a quota. Did somebody or some entity at One Stop get a reward for meeting a quota? It certainly seemed a real possibility. After 4 days of gathering information I called OPERS and complained and confronted them about One Exchange and my experiences.
They instantly overrode One Exchange and hooked me up with a trouble shooter. I was rescheduled with another person. This time I had my daughter Carrie with me on the phone. Carrie, a college professor and researcher, had also been examining the whole supplemental medical system and was prepared to ask relevant questions. Call it my age, call it a less analytical mind than she, call it what you will. But dealing with large bureaucracies has always been difficult for me. It is profoundly frustrating. Quite honestly, she has a much better grasp of situations and bureaucracies like this than I do. This time the person we talked to clearly had excellent and native command of American English, and was able to talk with us competently. After hearing of my prior experience with One Exchange, she immediately cancelled my previously assigned coverage and recommended what she termed a much better insurance carrier that would much more adequately cover my needs. She also recommended Alpha-Beta Health Rx Medicare Part D Rx insurance. They assured us that all my medications would be covered with NO Problems. So we took her advice. What else could we do?
Stay tuned. This gets worse!
This ongoing column is dedicated to those of us post 65’ers alone again, not by choice. If you identify with it, please step into the lifeboat and take a seat. We’re going to make it! I am open to ideas, feedback, and information that maybe helpful to all of us. You can reach me at tel: 330-562-9801 or e-mail me at Skipstaxidermy@yahoo.com