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OptumRx, a PBM owned by United Healthcare, is getting a bad rap. Medicare Part D mail order complaints. GA Medicare expert Bob Vineyard explains.
US based customer service is a thing of the past. Almost all carriers outsource operations to Asia.
Medicare drug plans are often misunderstood and with good reason. The plan is designed in DC by lawyers who will never use the plan, and it is run by insurance carriers.
What could possibly go wrong?
How do Medicare drug plans work?
Medicare Part D is confusing . Seniors will almost always buy the wrong drug plan and will spend too much every year. Average spending on prescription medication is $1 for every $6 spent on health care. If you spend $60 per month on doctor bills you can expect to spend another $10 on medicine.
Lower your medication bill by only using your drug card when necessary. The right drug plan will save a lot on brand names but you will almost always pay MORE for generics.
Consider paying cash or using GoodRx instead for maximum savings. Also look for drug plans that have a deductible.
Medicare Part D covers outpatient prescription drugs. Some Advantage plans have drug coverage built into the plan.
Did you know that some doctors and hospitals do not accept ANY Medicare Advantage plans? What happens if your claim is DENIED?
Medigap and Advantage plans cover the same things, but what you pay out of pocket for your care, and where you receive your care, is very different.
Original Medicare does not have networks. You can use any doctor or hospital anywhere in the US. Another plus is the ABN form which is only used with Original Medicare.
Advantage plans are managed care plans. Some are PPO, some are HMO. In 2018 about half the plans are HMO with the balance being PPO. How are Medicare Advantage plans like a store credit card?
If you receive non-emergency out of network care under a PPO you may have higher copay’s and deductibles. Your max OOP may also be higher. Some plans do not cap out of network charges.
Non-emergency out of network care charges may be denied if you have an HMO.
In 2019 most Advantage plans issued in Georgia limit your out of pocket for approved in network health care expenses to $6700.
The American Cancer Society tells us that more than half the 1.4 million new cancer diagnoses occur in people age 65 and older. Roughly 20% of retiree deaths are a result of cancer. Medicare pays for almost half of the $74 billion spent on cancer treatment. The elderly account for 70% of cancer deaths each year.
Some cancer centers, such as Mayo Clinic, Sloan Kettering and MD Anderson may not participate in certain Medicare Advantage plans.
Not all cancer responds to chemotherapy, but 80% of cancers are treated with chemo. Those treatments occur in an outpatient setting and are covered under Medicare Part B.
Chemotherapy drugs administered in a doctor's office or clinic normally fall under Part B. Medication from a retail pharmacy or by mail fall under your PDP.
This is why most of us chose a Medicare supplement plan in 2019. Bob Vineyard, independent Medicare insurance broker in Georgia, can explain your Georgia Medicare insurance options and will allow you to decide.
We represent several carriers including Aetna, Anthem Blue Cross, Humana and more.
According to the Mayo clinic, "new cancer treatments are routinely priced at over $100,000 per year of treatment."
Can I use discount plans like GoodRx if I have a Medicare Part D plan?
Yes you can.
You pick the way you want to pay for your medications when you turn in your prescription. You can use your Part D plan, pay cash, use GoodRx, or order from Canada. However you cannot "stack" coverage and use GoodRx AND your Part D plan.
Cash and coupon prices are often lower than insurance copays, and GoodRx is an easy way to make sure you’re getting the lowest price out there, whether you have insurance or you’re paying out of pocket.
Formularies are the list of drugs that insurers cover—and they’re shrinking. Fewer drugs are being covered and more drugs are being excluded. If your drug is not on the list, you might be hit with the full cash price of the drug unless you find other ways to save.
Just because a drug is on formulary doesn’t mean your prescription is covered. Even when a drug is on formulary, some insurers require patients to also get approval for the drug before they’re allowed to fill their prescription. It often means getting a doctor to send in a prior authorization form—and there’s no guarantee they will approve it.
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Should you stay away from OptumRx? Not necessarily. Depending on your Part D carrier, you may not have a choice.
Best advice is to understand your PDP and abide by the rules.
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