Joy is 89 years old and sharp as a tack.   She changed her Medicare Advantage plan last year and ran into some problems when the new company did not like the expensive blood pressure medication she was taking.  Joy had been taking Atacand for many years to control her blood pressure, but this drug is listed as a “non-preferred brand” by her Advantage plan.  So, the Advantage plan insurance company instructed Joy’s doctor to put her on a generic drug – or give generics a try.

Joy’s doctor prescribed a generic blood pressure pill and Joy did not react well to it.  The doctor tried another generic, and Joy continued to feel poorly on this drug as well.   It was at this point that Joy called me to say she had to change her Medicare Advantage plan because her old plan allowed her to take Atacand, even though she had an $80 co-pay for this expensive drug.

I explained to Joy that because Atacand is a “non-preferred drug”, her Advantage plan would “prefer that she not take it” – because it is expensive.  But I also told her the insurance company couldn’t force her to take generics if they don’t work for her.  So I called up her Advantage plan and talked to someone in the pharmacy department.  I half-jokingly asked if they expected an 89-year-old lady to experment with drugs and was told, “no, of course we don’t do that”. I was then told that the doctor’s office had not provided enough information for the insurance company to approve the Atacand prescription. 

My next step was to call the doctor’s office and talk to the person whose job it is to handle all the prescriptions. Imagine so much paperwork required for prescription processing to pharmacies and approvals from insurance companies that a doctor’s office has a full-time employee dedicated to it.  When I explained the Medicare Advantage company’s requirement for approval of an Atacand prescription, the employee at the doctor’s office understood what she needed to do.  She said she would fax the insurance company that afternoon.

I called the insurance company the next day and was told that Joy’s prescription for Atacand had been approved, and she could pick it up at the pharmacy.   I passed this information on to Joy and she was very relieved.  I then told Joy that she should never let the insurance company push her around.  They want people to take less expensive drugs, but they have to go along with the doctor’s wishes – if the doctor provides the right documentation and jumps through the necessary hoops.  And that’s how Medicare Advantage plans work as well as under-65 insurance plans.

This entry was posted on Monday, January 4th, 2010 at 9:54 am and is filed under Health. Tags for this post: health insurance, Medicare, Medicare Advantage, medicare advantage arizona, medicare advantage problems, medicare advantage tucson, medicare arizona, medicare change, Medicare Supplement, medicare tucson, part d, part d help. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.