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January 19, 2018

Medicare Part D Plan: It's Not About Me

When television first became a fixture in America's living rooms, a kids' show called "Winky Dink and You" appeared from 1953-57 on Saturday mornings. Those of us who grew up listening to "Big Jon and Sparky" on the radio from Cincinnati in the early 1950s weren't so drawn into the world of "Winky Dink" and his dog "Woofer" but our younger brothers and sisters (Baby Boomers) loved interacting with those characters. 

While the world of Sparky engaged our imaginations and fed our curiosity, Winky Dink and company seemed all about the individual viewer. Kids could send away two quarters and receive (in a real letter to them) a kit with a plastic screen cover and special crayons that allowed the viewer to be part of the television show. The crayons didn't work on paper and the screen cover stayed in place via static electricity but wouldn't stick any place else. It was like magic. Only those who could draw and write on the "magic screen" really understood the show. That was clever, interactive and kids felt special -- the television show was not only about the characters on the screen, but about the viewer too. 

This new programming gave the kids a feeling of control and getting something others didn't get -- a benefit. The kit wasn't seen as a marketing tool but as a benefit and a lifelong "benefits" love affair between kids of all ages and things "the media" portrayed as "benefits" grew.  It all seemed so innocent with no strings attached. No matter that the kids were a great new consumer base, a new market, and "that benefit" was really for the show's sponsors and not for the kids. Eventually, we all learned about advertising, the media in general and that there is no free lunch, or did we? 

Fast forward to now -- Big Jon and Sparky and Winky Dink are long gone and mostly forgotten. But, we still want benefits and control like we had with Winky Dink's magic screen even if that control was an illusion. 

We seniors have fallen down the rabbit hole of old age health issues and needs--reality with no illusions, right? When we become eligible for Medicare, we rush to shop for supplements--especially for medications. We pay a monthly fee for Medicare coverage and other monthly fees for supplements for traditional Medicare coverage and prescriptions. Unless we are hospitalized, prescriptions are excluded from routine Medicare and supplemental coverage. If we don't "get an Rx plan" at the onset of Medicare coverage and buy one later on, we pay a penalty forever after. When we were kids, we took the illusions of television as part of the fun and accepted what we saw without question. Now that old age circumstances have become a real player in our lives, we hold on to that same attitude--insurance is a benefit we pay for and it's a benefit for us, right? Well, yes and no. 

Lesson learned, again: Nothing is really about me or you for that matter. This is my experience and perhaps, you have found your way out of the rabbit hole of prescription supplements. If your coverage is excluded from this Rabbit Hole, great. Most of us aren't so lucky. 

Like many of you, I have several long time medical issues that require medications to manage. I pay my Medicare premium each month; I pay supplement premiums each month (these amounts continue to increase each birthday and vary from state to state). Sounds okay, right? Well, not so fast there, Babies. Let's look at the ladder down the Deep Rabbit Hole. 
  • We know that we can only make changes to our supplemental contracts during that little time window in late fall. Yes, they're binding contracts on our part. The insurance companies can and do make changes any time they wish. Step, step.
  • A short time before the time window of change closed for 2017, my prescription supplement notified me that two necessary medications would not be on their list of covered medications (their formulary). Oh, sure, my doctor could appeal that decision if no other medication would work. I encountered this "appeal process" a few years ago. The insurance company insisted that I try all the medications in that class before they would consider the appeal. My condition spiraled downhill on all the "equivalent" medications, I became sicker, had more tests and a new specialist -- and then, the appeal was denied in spite of the specialist's efforts. There was not enough time to find a different supplement before the time window closed in December 2017.   
  • My prescription supplement has a deductible that started out at one price but this year increased by fifty dollars -- oops! No one notified me but when I filled my first prescription in 2018, I found out by asking what the deductible is. 
  • Then, I found out that another of my medications had been dropped from the formulary with no notice. The retail price for these three irreplaceable medications almost tripled, two of them have no generic and the real "hat trick"??? Because they're not on the formulary, their retail cost doesn't apply to the deductible. The hocus pocus about filling the prescription for one month while I search for a replacement? Never happened. 
So, here's where we are on the ladder that does ever deeper: 
  • I can't change insurance coverage except during the time window insurance companies and Medicare set. 
  • The particular medications that will be available are preset. 
  • The deductible can be changed without notice and must be met before any coverage begins. 
  • Medications not on the formulary don't count toward the deductible. 
  • Medications can be dropped from the formulary without notice. 
  • And, my premium for this benefit continues to rise.  
So, as we get to the bottom of my Rabbit Hole, I find that I have no control or choice about my medications and I'm in a contract that only allows me benefits decided by someone else. Hmm. I researched this messy situation that has many similarities to the Winky Dink screen -- what you see is temporary and only gives an illusion of reality. 

Think I'm over dramatizing this? Check out Newsweek's cover story  (Friday, January 17, 2018) on Big Pharma and the power of 70 or so Pharmacy Benefit Management Companies that decide formularies, profit margins for pharmacies and what medications will be dropped. 

So when I say that my prescription coverage isn't about me, I wonder who it is about? Read Newsweek's take on all that. Here's a link to that story: 
Newsweek story on Big Pharma
http://www.newsweek.com/big-pharma-villain-pbm-569980

I'll be here waiting for my new magic screen to arrive and hope that Winky and Woofer on YouTube will be more user friendly.