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Sanford R. Altman For the Times Herald-Record
I recently brought a prescription to a local pharmacy. It was for a medication that required a handwritten prescription from my doctor instead of being called by his office.
I was therefore shocked when I went to pick him up a few days later and the pharmacist told me that my Medicare Part D drug plan now required that in addition to the drug. prescription written by my doctor's hand, I needed a form filled in by my doctor. The pharmacist also said that I could pay out of pocket, which would cost me $ 19 instead of $ 6. I was about to withdraw my credit card and pay $ 19 so as not to waste time calling my doctor, but as I did not need the medication right away, I restrained myself . As an advocate for the rights of the elderly, I was suspicious of the transaction and decided to dig a little deeper.
When I called my doctor, he confirmed that it would involve red tape and even suggested I go to a cheaper pharmacy. He obviously had the experience of this phenomenon and was not happy. Then I called the insurance company who runs my Part D plan. I asked why my doctor should fill out a form while he had already written an order to the hand.
The customer service representative told me that there was a list of medications that the plan had obtained from the Geriatric Journal for people over 65 (most Medicare beneficiaries) and the company's Insurance decided that any medication on the list would require pre-certification. I later discovered what I supposed to be "the list" and it contained pages and pages of medication. I asked the representative if it was about the law or plan policy. The representative did not know.
Then suddenly, it hit me. If older people have heard the same options that I've had at the pharmacy – ask your doctor and have the form signed or pay the high price – and need the order immediately, they would go immediately pick up their credit card. Or, they had difficulty getting to the pharmacy, or needed a means of transportation to get there, or if someone else was taking the order for them, it was more than likely that they would pay the higher price. Most people, in my opinion, would rather pay out of pocket than jump in all hoops just to be able to run the order.
What does this mean for the insurance company? That means one more prescription for which they do not have to pay. Multiply this figure by the 43.2 million seniors who rely on Medicare Part D prescription plans, which represents a considerable gain for insurance companies. Older people pay for insurance and companies do not have to cover the prescription. In short, it's a scam. It's subtle and it works. The only difference is that these plans were supposed to have been selected by the federal government, so that older people are far less likely to suspect that there is something sneaky in all of this.
My doctor later told me that, in his profession, it is well known that when an insurance company requests additional documents, it is nothing more than that. a "seizure of money". I was able to solve my case because I was relentless, but many seniors prefer to take the quickest route by paying out of pocket. But we should fight. And our representatives should fight. If my assessment is accurate and other plans follow the same procedure, the number of seniors affected and the undue profits reported by government-sanctioned insurance companies are staggering!
Sanford R. Altman is Senior Counsel and Senior Counsel. He is a member of the Advisory Boards of the Alzheimer's Association and the Office of Aging and Chair of the Montgomery Seniors Independence Project. You can contact him at [email protected] and at 845-800-0650. This column is intended to provide general legal information and not specific legal advice.
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