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Joinfortmill

(16,777 posts)
Fri Jan 10, 2025, 12:17 PM Friday

About Medicare Advantage plans, frustrated doctors, and an old gal who has changed her mind

Full disclosure: I've always had a MA plan and I never had a single issue regarding coverage or denial of service or medications. I've gone through cataract surgery and two brain stents for for a brain aneurysm that costs thousands of dollars. Then in 2024 I ran into this:

I developed Geographic Atrophy, better known as 'Wet' Age Related Macular Degeneration (AMD), which is characterized by the growth of unnecessary , damaged, blood vessels that leak blood and fluid into the eye, causing central vision loss. The most common treatment is ongoing eye injections (yup, a shot into the eyeball) that temporarily stop the proliferation of these rogue blood vessels.

There are three or four different medications (most of these medications are anti-cancer drugs (It gets complicated) that are injected into the eye at a cost of $50 to $2000 per injection. The $50 shot works sometimes. The higher priced medications work all the time.

So, this is what my Retina Specialist (who is DISGUSTED) with MA plans told me today after I had my 4th shot in four months. Because one of the previous three shots was not the lowest cost drug, but a sample he used, it did not meet their 'requirement' that three shots of the lowest cost drug be used AND is shown not to be working before they will approve the higher priced drugs.

So, there you have it. The physician cannot provide the best, most appropriate medication for a disease that could well cost me my central vision. So, after ten years of coverage with an MA plan, I am going to enroll in original Medicare as soon as I meet a qualifying event.

I don't know what the moral of this story is. All I know is the decisions these health insurers are making are not based on sound medical advise, but on saving a few hundred dollars at the risk of human lives and the loss of payments directly from Medicare, because you can't get blood from a stone or dollars from a dead old gal.

19 replies = new reply since forum marked as read
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About Medicare Advantage plans, frustrated doctors, and an old gal who has changed her mind (Original Post) Joinfortmill Friday OP
Trump and his cronies gab13by13 Friday #1
If that happens things are gonna get much worse Joinfortmill Friday #5
We all need to be aware that the insurance companies would not be so aggressive, nor spend so much, on marketing Attilatheblond Friday #2
Please explain the 'qualifying event' you mentioned EYESORE 9001 Friday #3
If my MA is not offered in my State next year Joinfortmill Friday #7
Medicare Advantage djtexas Friday #4
There are exceptions. Joinfortmill Friday #8
You can always get back on Medicare dpibel Friday #16
This is true. I will likely pay more and/or Joinfortmill Friday #17
Similar problem for FIL with ELIQUIS...he may have to rely on $2k a year cap JT45242 Friday #6
Not sure if your FIL qualifies gab13by13 Friday #12
Thanks...he tried that JT45242 Friday #14
Honestly, I don't think any healthcare system can handle using the most expensive drugs when cheaper ones Silent Type Friday #9
I have no issue with a drug that works... Joinfortmill Friday #10
Totally agree once it's clear cheaper med isn't working. I just don't support going to the most expensive first because Silent Type Friday #11
Best of luck. Joinfortmill Friday #13
Often they make you try cheaper even if it is contraindicated JT45242 Friday #15
Wishing you a good outcome. Joinfortmill Friday #18
By accident we found a slightly longer duration between shots helped my mom IbogaProject Yesterday #19

Attilatheblond

(4,805 posts)
2. We all need to be aware that the insurance companies would not be so aggressive, nor spend so much, on marketing
Fri Jan 10, 2025, 12:23 PM
Friday

if they didn't stand to make a LOT of profit on these policies. And the way they make the profits is by denying coverage.

EYESORE 9001

(27,664 posts)
3. Please explain the 'qualifying event' you mentioned
Fri Jan 10, 2025, 12:26 PM
Friday

I haven’t had occasion to butt heads with my MA provider yet. I haven’t switched over to regular Medicare totally, as it would require paying a monthly premium, and I’m a cheap bastage. Still, I prefer not negotiating with a death panel composed of hospital administrators and corporate bean-counters.

Joinfortmill

(16,777 posts)
7. If my MA is not offered in my State next year
Fri Jan 10, 2025, 12:38 PM
Friday

Which may well happen. It's happened often to me in the past, I'll switch.

djtexas

(36 posts)
4. Medicare Advantage
Fri Jan 10, 2025, 12:32 PM
Friday

You may not be eligible for original Medicare.

I think it is an unfortunate restriction (in the fine print) that if you enroll in a Medicare Advantage plan that you can never get original Medicare.

Please report back what you find out.

dpibel

(3,454 posts)
16. You can always get back on Medicare
Fri Jan 10, 2025, 01:40 PM
Friday

The problem is that you may not be able to get a supplemental plan, or may have to pay through the nose for one.

Without a supplement (which is, for all the wailing about Advantage, private insurance), you're on the hook for 20%.

JT45242

(3,015 posts)
6. Similar problem for FIL with ELIQUIS...he may have to rely on $2k a year cap
Fri Jan 10, 2025, 12:38 PM
Friday

Regular medicare D it is between $50-60 a month.

Medicare advantage put it on name brand formulary and you must show other generic blood thinners didn't work.

His best option is to try to quit his advantage and go back on regular medicare part D or just suck it up and pay $400 a month until his prescription total for the year hits $2000 thanks to Biden.

It is so hard for me to not say..you voted for the felon three times. Reap what you sow.

gab13by13

(25,564 posts)
12. Not sure if your FIL qualifies
Fri Jan 10, 2025, 01:07 PM
Friday

but it is worth a phone call. I was paying 400 dollars for a 90 day supply of Eliquis and now I am paying 10 dollars a month. It has nothing to do with income, it is a program done through Bristol Myers Squibb.

Call this number to find out about eligibility

1-855-ELIQUIS - 1-855-354-7847.

JT45242

(3,015 posts)
14. Thanks...he tried that
Fri Jan 10, 2025, 01:09 PM
Friday

Got two months cheap and is no longer eligible.

Big cluster f....

Wife called me last night. Asked me try to find a solution.

I do appreciate the helpful link...

Silent Type

(7,558 posts)
9. Honestly, I don't think any healthcare system can handle using the most expensive drugs when cheaper ones
Fri Jan 10, 2025, 12:50 PM
Friday

work well the vast majority of time.

Medicare -- what we consider the model for universal healthcare -- has coverage requirements for treating macular degeneration too.

I'm at high risk of macular degeneration. If it gets to that point, I'll try the cheaper med that is like $100 to see how it works just because it makes sense. Other folks will rush to the expensive, heavily advertised meds.

Joinfortmill

(16,777 posts)
10. I have no issue with a drug that works...
Fri Jan 10, 2025, 12:57 PM
Friday

In my case, my condition is worsening and They're denying medication that would be effective.

Silent Type

(7,558 posts)
11. Totally agree once it's clear cheaper med isn't working. I just don't support going to the most expensive first because
Fri Jan 10, 2025, 01:01 PM
Friday

some doctor -- who probably is invested in companies that make the more expensive drugs -- recommends it.

I hope your treatment is successful, the little blurry spots get annoying after awhile especially when they get bigger.

JT45242

(3,015 posts)
15. Often they make you try cheaper even if it is contraindicated
Fri Jan 10, 2025, 01:12 PM
Friday

All the cheaper drugs that my FIL should have to step up through to get the new name brand have potential major problems with one of the many other cancer or other meds he is on.

IbogaProject

(3,896 posts)
19. By accident we found a slightly longer duration between shots helped my mom
Sat Jan 11, 2025, 12:28 PM
Yesterday

We were doing every 6 weeks and once when delayed to 8 weeks the condition improved. Not sure if her's was wet or dry. But yes, MA plans have profit seeking and those delays in care are often dangerous.

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