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  • Puddiesmom

    Hi Kris,

    I have a question.  I already called Medicare and my insurance company, and they both told me this could be done, but I would like your opinion.  I lodged a complaint - grievance - with my insurance .   I take a pain medication that is a narcartic that has been a generic drug for at least 15 or 20 years, and they have charged it as a generic copay.  I also take a brand name drug that has now become a generic drug.  What they are doing effective 1/1/13, is charging a tier 3 - non approved brand name drug - copay for the generic drug, which they are moving to tier 3, and leaving the drug that is becoming a generic at it's tier 3 copay.  Medicare said that they can do whatever they want, and the insurance company says that the plan set the drug prices.  Can they really do this?  My husband lost his job, and the only income we have is my disability, and SSA says I make too much money to qualify for SSI also.  Any response would be greatly appreciated.  Thank you.


  • InsuranceMgrKris9
    Hi Puddiesmom,

    We have a benefits team here that would love to help you with your specific Medicare questions and walk you through some potential solutions.  Please call us at 1-800-344-4867 and ask to speak with a benefits Navigator.  If no one is available please leave one of us a message and we will get right back with you. 

    All my best,

  • maria1
    Hey Puddle....

    That was really smart of you to lodge a grievance, I didn't think of that. We ought have a voice somewhere.

    My insurance has what they call, non preferred pharmicies and preferred pharmacies and will charge higher prices for non preferred pharmacies filling prescriptions., Besides their pricing changes. Monthly fee increases copay increases.  They also have what they call PA clauses for tier 5 prescriptions, Betaseron has to be preapproved so too for Lyrica. Betaseron they have a copay of 33percent or roughly twelve hundred dollars a month. tsk tsk. They also include phone numbers for agencies to call for extra help to pay for the copay. Doctors and patients use to decide on patient care now it is the insurance companies and the government.
  • maria1
    My friend told me to contact the senior most senator in my state, and today  I got an answer.       The centers for medicare and Medicaid services allows part d prescription drug plans to include both preferred and nonpreferred pharmacies, with differences in cost sharing between these two types of pharmacies. In part d plans with preferred and non preferred pharmacies, beneficiaries copayments & coinsurance are less for an innetwork pharmacy than for an out of network pharmacy, According to cms rules, pharmacies in networks with preferred and nonpreferred pharmacies cannot increase overall costs to the medicare part d program cannot have cost sharing that is significant that it discourages enrollees in certain areas, including rural areas or inner cities, from enrolling in part d. As you may knoiw, cms requires part d plans to permit the participation of any willing pharmacy that meets the plans terms and conditions.. Many independent pharmacies however,, see the creation of preferred pharmacy networks within part d plans as inconsistent with cms''' any willing provider'; regulations, because they have not been invited to participate in a  number of preferred networks, which often include large pharmacy chains . In response to the  growing popularity iof part d plans with preferred pharmacy networks, in 2012, several independent pharmacies sued the department of health and human services and cms. charging that nothing in the medicare part d statute or  its legislative history allowed for the operation of part d plans with preferred pharmacies..   You may be interested to know that cms is currently scrutinizing preferred pharmacy networks, with the agency recently expressing concern about aggregate drug costs for the top brandnamed and generic drugs in preferred networks,. I know how important independent pharmacies are to preserving quality healthcare and consumer cholice for the people of Missouri and should legislation regarding preferred pharmacy networks come before the full senate for a vote, I will be sure to keep your views in mind.  Claire mccaskill                      [of course they used caps and punctuation where I cut corners}   Be sure to contact your senior most senator and voice your dissatisfaction, the more the merrier --- they work for us.
  • dmshaeffer
    I am also investigating why the structure of Medicare's Part D formulary places MS medications in Tier 5 and why the plan bars plan recipients from appealing to their insurance carriers to move Avonex, Betaeron, Extavia, and Rebif to a lower tier. The MAPRx advocacy group, to which the NMSS is a member, published a white paper last year addressing the adverse and discriminatory effect of the Part D formulary structure on chronically-ill Medicare recipients who must pay a disproportionately higher price for Tier 5 specialty meds; the fact of which is inconsistent with other Medicare programs that serve the medical needs of seniors. The discriminatory effect of Part D's specialty drug tier was introduced to Congress by Lousiana Rep. Bill Cassidy in March 2013 as HB 1239, "Accessing Medicare Therapies Act." HB 1239 would provide relief to all Medicare Part D enrollees on Tier 5 meds, including MS patients, but is stalled in committee at this time. I have addressed the issue with Arkansas Senator Boozman and Congressman Womack and am awaiting responses. Unfortunately, this is a legislative issue which will take the proverbial Act of Congress to remedy. In the meantime, MS patients on Tier 5 meds will continue paying higher prices! Unfair and immoral!!
  • maria1
    Here is todays reply to Ms McCaskill:   Dear Madame Senator,  Perhaps I forgot to mention that the spokesperson at United Healthcare said that Medicare signed off on all the policy changes for 2013. How can CMS effectively investigate something that they approved? Should this not be something for a Congressional Hearing ? And can you personally get something started to protect small business in Missouri and the chronically ill in Missouri and America? AARP claims they do not get involved with insurers policy but strive to get the best value for their members. Is there no one willing to fight for us who have challenges with daily life or are we to become the majority disenfranchised?   Most Sincerely,
  • maria1
    I just received a call from Toi at UnitedHealthcare who handles medicare complaints. She said that medicare approved the documentation for the policy changes. She said that there will be no policy changes during the year and whomever has the ability to make those changes is not in her department.

    If you are on medicaid you can change your provider at any time and do not have to wait for the November schedule.

    I shall call back Medicare tomorrow., 
  • maria1
    Toi called me back to say she did some further research and was putting the two pharmacies on a list for next years contracting.
  • maria1
    I found a site called pissed consumer!  If you google united healthcare and scroll down the page a bit you will find consumer complaints which will be pissed consumer,are more than one hundred complaints, if you want to make a claim or comment annomously you can. I posted a complaint.

    Add your voice to the pissed consumer, it wont happen overnight but we will make our voices heard and get the ball rolling, the more the merrier. please stand up and be counted, we can not do this alone,
  • maria1
      Just got a response from the governors office saying that they are forwarding my email to the Director of the Missouri Department of Insurance, Financial Insttitutions and Professional Registration (how about that for a hodgepodge of business) and have requested that tthe directior respond to me in a timely fashion.  Closer to something?
  • maria1
    Puddiesmom and everyone else,  Medicare is a Federal Contract so I finally got somewhere to lodge a complaint.  If you live in Iowa, Kansas, Nebraska or Missouri  CALL 1-816-426-5783 and say you have a Complaint for Part D Plan and tell the story to the person who will take the complaint.  I lodged a complaint against UnitedHealthcare stating that UnitedHealthcare is now in 2013 charging more for prescriptions filled by my local pharmacy.

    They asked if since I live in a rural area would there be an accomodiation for me. I told the person on the phone that I did not believe what the people at UnitedHealthcare told me, that when I asked for confirmation of the conversation for the cost of prescriptions they would not put it in writing, also when I checked on my prescriptions someone told me my provigil prescription was grandfathered in and I would not have to have paperworksubmitted. Then I got a notice in the mail that the provigil was not covered because there was no paperwork submitted.

    FOR ALL OF YOU WHO DO NOT LIVE IN THE FOUR STATES ABOVE, go to to find the location and phone number of your local medicare office and call and lodge a complaint. The more the merrier.
  • maria1
    Hey Puddiesmom, havin fun?

    I did some more research, Unitedheathcare bought Optum which is the company that is the mail order drug company. If you go to unitedhealth group, you will see all the companies united healthcare has purchased in the last five years. Also, if you look at their investors, you will find many mutual funds, and banks owning the stock. So, the fight is even bigger still.

    I THINK, which means I still have to think more about it, that i will send an email to wolf blitzer and see if he wants to take on the world(all the people involved with unitedhealthcare). My local us representative has not answered either emails yet.

    I have to rethink the aclu, because of the involvment with the government and medicare, i dont know if i can write that letter yet? got to think some more.
  • maria1
    1.19.13 nothing new to report, no responses yet to the emails. Dont know if the newspaper published the letter either.
  • maria1
    Here is a copy of the letter I sent to the ACLU  My suggestion is to find the local branch email and send them a copy, but eliminate my personal info. The more who send this the better.

    Dear American Civil Liberties Union,

    If you have ever been sick or know someone with a chronic illness, you are aware of the important role the local pharmacy plays in alleviating some of the stress. You know the relief of seeing someone and knowing who you are speaking with. The local pharmacists, oftem members of the community, someone you see walking down the street and you both wave hello. They are the people who take the stressful edge off being ill, having to take medication and being afraid. Without these people, the strangeness we feel would be worse. We appreciate how they help make us feel safe.

    Now, UnitedHealthcare is penalizing us for wanting to do business with our local pharmacies. They want us insured, to use a mailorder pharmacy or large chain like Walgrens. If we choose to have our prescriptions filled by our local pharmacy, which UnitedHealthcare has classified as nonpreferred pharmacy, we are charged more for our copay portion of the prescription.

    I have been insured by AARP MedicareRX Plans through UnitedHealthcare since 2006. Boring Rexall Drug and Cole Camp Pharmacy have been preferred pharmacies until 2013. They have now been moved to the nonpreferred pharmacy statis at UnitedHealthcare. I am also a senior with more than one chronic medical condition which causes me to need the services of the local pharmacy almost as often as the grocer.

    That I have been told where to have my prescriptions filled or should I say, where it will cost me more to have my prescriptions filled if I choose not to use UnitedHealthcares preferred pharmacies causes me extra tendsion and stress. If i see my physicial and a prescription is written I must drive more than forty miles one way to have the script filled or wait an additonal day or two to have it delivered.

    Had i been able to see and read the notice of policy changes UnitedHealthcare sent last year, I would have changed my provider, cataracts and cataract surgery made that not possible, But that is not the point, there are millions of seniors doing business with UnitedHealthcare because they were referred by AARP, a group they trust. Now AARP says they do not help UnitedHealthcare set policy but do strive to find value for their members.

    I have heard that AARP owns the mailorder pharmacy that UnitedHealthcare uses, but my email to AARP requesting verification has as yet been unanswered.

    If UntiedHealthcare continues with this policy of listing my local pharmacies as nonpreferred it will probably put the local pharmacy out of business. The chronically ill are among the poorest of seniors, an already financially strapped group, and we will be forced to wait to have prescriptions filled by people we do not know and we will have  to wait for the mail to be delivered to get the medication we need.

    PLEASE, can the aclu get involved in helping undo this error in judgement by UnitedHealtcare, the do not hear or do not care what we are saying.


    [I had to focus on one point in the hopes we get their attention]

    It is not even noon on Monday 1.7.13 and the aclu has already responded. They only act on government issues, and referred me to local legal aide. Must think anew!
  • maria1
    We could post the letter without the aclu mentioned. Everyone post it and share it with everyone, on facebook and anyone in your mailing list. Change it anyway that suits you. If you have a blog, post it. I already tweeted that UnitedHealthcare is putting local pharmacies out of business.
  • maria1
    I have sent a copy of the Dear Americans letter to the local newspaper. In addition I sent an email to my us represenattive. 
  • maria1
    Anyboby hear of the Senior Citizens League? I sent them a qjueery about unitedhealthcare to see if they were fighting for the change in policy, that was today.
  • maria1
    Called the lawyer yesterday to make sure he got the email, and instead of getting his voice mail he answered the phone. We chatted several minutes. He was taking the email home with him to study it, then he said he needed time to think about it and would call me back before the end of the week. The idea of a class action suit got his interest. So we got an ear to begin with. I will report the next development as it happens.
  • maria1
    Hey Puddlesmom,

    I spoke with one of the pharmacists who said that AARP owns their own mail order pharmacy and that is why they are trying to force out the local pharmacies.

    What do you think of the idea of maybe speaking with the ACLU  to see if they would take us on as a group, a class action suit?
  • Puddiesmom
    Hi Maria,

    Thank you for responding.  My insurance - I'm on Medicare - also has preferred and non-preferred pharmacies, and does the same higher pricing.  You mentioned that they change fees and copays monthly.  I don't think they can do that.  Once they have published hteir prices for the year, they are locked into that for a year.  If you are on Medicare, call them and conplain, or if you are not, call your state insurance board and complain to them.

    I would definitely call some of the numbers that they provide, but I would make the first call to the drug manufacturer to see if they have a program to help. 

    It sure is nice that the insurance company went to the doctor with you isn't it?  Glad they can make the decisions.  LOL!