OptumRx Stay Away? – GA Medicare Expert Weighs In

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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.

#GeorgiaMedicarePlans #GAMedicareExpert #Turning65

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.

#BESTGeorgiaMedicarePlans #GAMedicareExpert #GAMedicareVideos

OptumRx Stay Away? – GA Medicare Expert Weighs In


16 thoughts on “OptumRx Stay Away? – GA Medicare Expert Weighs In

  1. Optum RX, CVS Caremark & Express Scripts own 85% of pharmacy benefit managers. They all keep lowering the bar and engage in similar greedy and unethical steering to their owned mail-order pharmacy. It’s time to reach out to our Attorney Generals and demand that the forcing to mail-order and removing the crucial face to face relationships. We should have options in our coverage for our trusted pharmacy. Mail-order pharmacy risks patients lives by life-threatening delays, lack of temperature monitoring and lack of face to face interactions for patients with chronic https://www.change.org/p/attn-all-attorney-generals-hold-cvs-caremark-optum-rx-express-accountable-for-life-threatening-delays-risking-lives?fbclid=IwAR2nXXUeAN-q80LLOjAIJ3qDBQM4fmDEbDa9_z49jhrWieaoycI00llu87g

    • Thank you for continuing to post which allows me the opportunity to respond and post more links to my YT videos. This will help to increase traffic, gain more subscribers and clients. How are #MedicareAdvantagePlans Like a Store Credit Card? https://youtu.be/p0j41FsfHbA

    • @Georgia Medicare Plans Sorry. I’m not trying to upset you. I’m just trying to inform you of what is happening due to PBMs and unfair business practices. I believe non one should have to use a GoodRX card when they are paying for their coverage. I believe seniors and our disabled should have a right to have a relationship to their trusted pharmacist and I believe our pharmacist should be paid fairly. Optum RX CVS Caremark and Express Scripts own 85 % of the PBM market and selecting another plan that doesn’t engage in similar behavior is almost impossible for many people. I will keep fighting for our community pharmacist. I want to ensure that my child and all people have the across all coverage to their face to face relationship with their providers. Again, sorry to have upset you, What I do is speak for the patients. Here is a less than one minute video explaining PBMs like Optum RX https://player.vimeo.com/video/319979701?fbclid=IwAR0IUJGuKZrPefdmKqSkbKllIlAB06WCfUJqPAVfu7P3fo8zImGm5YLaxz8

    • Nothing upsetting about your comments. With over 40 years in the health insurance business, working on the carrier side but mostly direct with clients, I have a pretty good grasp of health care in general and the specifics of “big PHARMA”, PBM’s, kickbacks, AWP and other pricing schemes.

      I also know that fighting the money people is mostly a waste of time and energy. I make a difference every day for my clients by showing them how to #NavigateTheMedicareMaze (including Part D) and where to find the best value.

      And I do appreciate your comments. They allow me to get more traction for this video and others on my channel. How to Find the Best Medicare Drug Plan. https://youtu.be/eVOXJTCOWr0

    • I understand. Patient advocacy isn’t for everyone. I can’t allow myself to feel hopeless when I have young children. One who will be on medications every 12 hours forever. I feel like we both feel like we are helping others and in some way right? I do feel like major changes are on the way. Will the changes benefit patients or corporations? Is there a way both can win? The next few years will be interesting, yet crucial to patient care.

    • Patient advocacy is noble and can be rewarding. I fight for my clients every day but with a different approach. Learning as much as I can about how the system works, and sharing that information with everyone via blogposts, YT video’s and more educates beneficiaries. My goal is not to make them experts, but give them enough knowledge to understand there is a way to get most of what they want and need.

      I tell clients they don’t need to be an expert on Medicare. That is my job. If they have questions, I can provide answers.

      HIPAA prevents most of the direct carrier interaction on their behalf, so I have to resort to coaching them through the process.

      Winning is not about one side getting everything they want and the other receives nothing. Winning is compromise where both parties feel they have gained something.

      The health care side of original Medicare is relatively simple thanks to the absence of managed care. Or as I call it, MANGLED care.

      But Part D is a labyrinth. I am involved in this part of Medicare almost daily and still learn things. There is no way the average person can understand drug plans. That’s why they need an expert. Specifically a #GAMedicareExpert. Shameless plug follows. https://youtu.be/hFQsV9p4mac

  2. I am grateful that Bob has tried to explain the variables about prescriptions for Medicare recipients. He offers a teaching moment for clear, structured and organized discourse. What exactly is your topic? Start with that!

    • @Anna Lyon, thank you for the kind words and “attaboys”. I do what I can to help. Take care, bv

  3. OK, great – I was notified by Aetna last month that my ‘scripts are now coming from Optumrx. These greed bass turds.
    Very informative, thank you, Bob

    • Hi Franklin – Thanks for visiting and leaving a comment.

      Aetna sold their Medicare Part D coverage to Wellcare. So I assume you have an Obamacare plan or employer group plan. Is that correct?

      Aetna had been using CVS Caremark. So now it’s OptumRx?

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