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 lay down and get steam rolled by them. No one seems to have our back! This is my story so I am here to tell you that it is true and I tell it to you now.
In the previous edition we explained how the Ohio Public Employees Retirement System (OPERS) made the decision to stop offering supplemental medical insurance to us retirees and, to make things “nice” again hired a firm called One Exchange to help us all get our own supplemental Medicare insurance. The whole process 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. The result was that many of us felt that we were not dealt with fairly by One Exchange and it took several consultations with One Exchange and many consultations with people and firms outside the OPERS system to begin to understand what we were getting into. Even then, individually contracting with the massive health and insurance industry is intimidating and foreign to us retired people. We are not lawyers or corporate executives.
Fast forward to February 21. I’ve now used the AARP Medical Insurance for annual visits to my doctors. Note that this is not the same company as Alpha-Beta Health Rx. Most often the actual medical coverage is offered by a different provider than the Medicare Part D Rx insurance. As was guaranteed, there has been no prepay or copay demanded at the office. I can’t say yet whether any additional charges have been issued. But so far, so good on that front. But the Part D Rx coverage nightmare began exactly one day after my visit to the doctor. For openers on that day I received a letter from Alpha-Beta Health Rx stating that they were required to notify subscribers that they were, as of January 21, 2016, under sanctions from Medicare as a result of an audit done in 2015 and that they could not advertise or accept new members until problems were rectified. The problems cited were:
1. Not conducting sufficient outreach to providers and customers to obtain information needed to make an appropriate decision regarding drug coverage.
2. Incorrectly denying drug coverage
3. Failing to provide customers with a one-time temporary supply of a drug (also known as a transitional supply)
4. Failing to process requests for drug coverage correctly and/or on a timely basis
5. Providing inadequate or incorrect information in beneficiary communication
6. Failing to have an effective compliance program.
The letter also urged us current customers not to worry but by law, because of this sanction we could appeal to Medicare and ask to be changed to another drug program. This was ominous, foreboding, and foretold of what was to come.
As usual my doctor called in my prescriptions to this new provider—Alpha-Beta Health Rx, also confusingly known as “My Lifeboat”. Immediately I was notified that three of the 5 prescriptions would be sent within a couple days. A fourth one would require that I prepay (and overpay) $125 for what is an over the counter drug (Omeprazole) or as it is known in the stores, Over The Counter Prilosec. Another drug, ABC, was not on their preferred or “formulary” list so therefore was denied. When I pressed this issue they said my request would have to be reviewed. I was switched to another person. This person confused the issue, said my prescription was denied, and that they would ship me XYZ instead. I explained that indeed this was not what my Doctor ordered, that I had been tried on XYZ several years ago and found the drug to be very harsh in side effects and highly unsatisfactory. This is why my Doctor prescribed ABC which has much fewer side effects. I pointed out that Alpha-Beta Health Rx could not switch prescriptions on me, that this is exactly why Medicare has sanctioned them. I then recounted the six cited violations resulting in their being sanctioned and that they were indeed now leveling these six violations on me. On my mention of the word “sanctioned” she immediately switched me to an intimidating, stern, deep voiced, firm sounding gentlemen who loudly started off the conversation with, “I understand that you are concerned with the Medicare sanction….. let me tell you that”…. I cut him off and clarified that I want and expect my prescription drugs just as the doctor ordered. “You cannot deny me the drugs that a doctor has ordered. You are not physicians”, I said. Needless to say I got no satisfaction from him. He referred me to a person at another number who expounded on the possibility that a physician could call this specified number and request an override of their decision. Much later in the day though I received a computer generated phone message from Alpha-Beta Health Rx that my override had been denied. I immediately called the override number and expressed my great displeasure. They back pedaled and stated something to the effect that the computer generated messages are pre-programmed, blah, blah, blah, and sorry for your displeasure. Next morning in the mail though, I got an extremely ambiguous formal notice that my Uloric was not being filled and that I had some very unclear rights to appeal this to ???????? I don’t know who; it certainly wasn’t clear! My recourse was to file an appeal or complaint with Medicare. Which we promptly did!
My daughter called Medicare, explained the situation with Alpha-Beta Health Rx, and the Medicare representative immediately offered to switch me to a new insurance carrier. We, of course, did so! In the meantime, though I had already had my Doctor call Alpha-Beta and try to override their decision. He also called in a prescription to my local hometown pharmacy, Mantua Station Drugs. I figured that in the event of the worst case scenario I would have to pay the full price ($270 for a 30-day supply), but at least I would have it. Kidney stones are horribly painful and dangerous. Having had several over the years I am here to tell you that I would go to the end of the earth to get the medicine to stop them. They did fill it, and charged it to Alpha-Beta Health Rx. This was a “through the back door move”, if you will. Within two days I got a letter from Alpha-Beta conceding that, yes, they were required by law to provide me with a 30-day supply, but only a 30 day “transitional” supply. This was nothing less than an after the fact concession/admission by Alpha-Beta that they were well aware of the Medicare sanctions and continuing to be out of compliance until I forced the issue. Next day I got a letter from Alpha-Beta stating “You are no longer a member of our organization. Therefore, the review would go no further. Then about a week later, March 10, I received a letter confirming that my coverage would end on March 1—another after the fact concession/admission in an attempt to rationalize their non-compliance.
By then I had gotten a confirmation letter from my new Medicare Plan D supplier—Silver Dollar. We (my Doctor and I) are now in the process of switching the prescriptions to that company. Interestingly enough that new company did fill a 30-day supply of ABC for me from Mantua Pharmacy. Also interestingly, the price to me was fully one third less than the price that Alpha-Beta charged me.
Where are we now? Stay tuned for part three.
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
