Home / Pharmaceuticals / Choosing or Updating your Medicare Part d Provider and Coverage

Choosing or Updating your Medicare Part d Provider and Coverage

Okay boys and girls, say it with me now – “Let’s go, Aetna!” You know if it is past November 15th, it must be time to choose a new Medicare Part D provider! For the fourth time in three years (counting Year One, when someone switched us to another provider without our knowledge and we had to switch back!) we are moving to another insurance provider for my grandmother’s prescription drugs. It seems that Humana, who was our provider in 2008 – and who had amazing customer service – is no longer an affordable fit.

In 2008, Humana gave my grandma “lifetime authorization” for coverage of a drug known as Aciphex, which controls acid reflux. Her previous provider, CignatureRx had required we try other alternatives – other prescription options and OTC Prilosec. None of these worked, and Grandma’s doctor faxed all of the appropriate documentation to acquire a waiver for CignatureRx to cover Aciphex, which is between $150-170 for 30 tablets. In 2008, this came up with Humana, and all I had to do was to tell them that we had been down this road the previous year…I don’t believe the doctor had to fax over anything, but maybe. At any rate, they verbally gave me the “lifetime authorization.”

The 2009 formulary for Humana does not list Aciphex. Additionally, there will be a $10.60/month premium assessed on even those on total government assistance (Medicare and Medicaid). If a person can’t pay this premium, Medicare picks a new plan for you. The last time Medicare picked a new plan (remember, without our knowledge?) it did not cover at least 3 of the drugs my grandmother takes! So I am not going down THAT road for sure! So…I decided if all we would be out was an additional $127.20 per year, that was worth not having to go through hoops to change providers. But just to be sure, I called Humana. Four Customer Service reps, the Medicare rep and 2 days later, I had three people telling me that there would be a monthly premium, two said there would not, NONE of them knew about the $295 “Pre-Initial Coverage Period” fee, and all of the Humana reps said there was indeed a “lifetime authorization” for Aciphex.

What all but the last Humana rep failed to tell me is that for Humana, “lifetime authorization” means until the end of the calendar year. Then all bets are off and you have to appeal/re-apply. My Medicare rep told me from the start that… “Aetna looks like your best bet.” In the end, she was right… and I called her to tell her so and to clue her in on how Humana views “lifetime authorization.”

So, I made the move to Aetna a few days after the November 15th opening date. My head is spinning from all of these calls and menus and back and forth. I now know the weather in New York, North Carolina, and Dallas! I’ve been directed to www.medicare.gov more times than I can count – and I already have an account there with my grandmother’s drug info safely stored for quick retrieval, which surprised most of the reps. This is not my first rodeo!

Sadly, though, this maze of confusion will cause countless elderly people who have no advocate to throw up their hands, pay the extra – or worse yet, let Medicare decide for them what plan they get – and they will have no choice. I explained to the Medicare rep that she and her predecessor (who had the good sense to retire and keep what was left of her sanity) are dealing with a generation who may know how to send an e-mail or read something on a website, but for many of them, choosing a prescription drug insurer online is far beyond their scope of computer expertise. Many have never even seen a computer. Unless they have someone to do this for them, they are out in left field.

I also learned from my Medicare rep that I can expect to change plans every year – as the formularies change. She said Medicare regulates some things, but not all, and the private companies can regulate prices and what is covered, and how much, to a large degree. I told her I doubted the average American knew this. I certainly didn’t! I was hoping that I had found a company we could settle in with for the long haul, and Humana would take care of my grandmother for the rest of her days. Not so! As long as we have this Medicare Part D program, we can look forward to spending the weeks before Thanksgiving studying formularies, reviewing and comparing plans on www.medicare.gov and trying to wade through the maze of confusion to figure out which plan is the best and most affordable for the coming year!

I don’t mind doing this for my grandmother. I really don’t! But it boggles my mind to think about all of the people “out there” who have nobody to do this sort of thing for them. They have no advocate to file the papers to continue their monthly food stamp allotment, their annual assistance with utility bills, their application for Home Health care and whatever else the Department of Human Services feels needs to be added to their file cabinets. They have no one to go to the pharmacy, the utility company, and the bank and secure copies of their statements to prove to the government agencies that THEY HAVE NO MONEY! Since my grandmother’s only income is her monthly Social Security check, and the government seems to know everything else about all of us, you would think they already know how much she has and what she can or cannot afford! It would also stand to reason that if she could not pay for Aciphex on December 31, 2008, she still would be unable to afford it on January 1, 2009. That should not require another round of papers from a family physician – especially for the same insurance provider!

So Happy Winter! I hope you have received your formularies and are carefully examining all of the fine print. I also hope you only have to speak to three representatives or less to get definitive answers. May your phone menus be short and get you to the right person on the first try!