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Sat Mar 8, 2014, 05:55 PM

Managed Care Denies Coverage for Generic Albuterol, Will Only Cover----Name Brand Albuterol

I have blogged before about Managed Medicare abuses. About how a loophole in health care law allows the plans to bill their own internal Q&A as direct patient care. And about the massive number of medication denials which they issue, most of which are designed to create patient and doctor hassles rather than save the insurance plan money.

The latest target: albuterol inhalers, the inhalers that every asthmatic uses for asthma attacks now that all the competitors are gone. That's right. Albuterol is the only drug available in the U.S. for use as a rescue inhaler. There is nothing else that can take its place. And, because of reformulation issues, all of these inhalers are extremely expensive--too costly for a cash strapped senior or disabled person to buy his or her own, no matter how badly he or she is wheezing. So, how did I get not one but three Medicare Managed Care denials for generic albuterol inhalers in one day?

I wanted to know the answer to that one myself. So, once my medical assistant got a representative of the insurance plan on the phone and discovered that while the plan did not cover generic albuterol inhaler, the plan did cover Pro-Air--a name brand albuterol inhaler, I took the phone.

"Why?" I asked the young man at the other end of the line. "Does Medicare Advantage Plan C cover a name brand albuterol inhaler but not a generic albuterol inhaler? Why can't the participating pharmacy substitute Pro-Air for 'generic albuterol inhaler'?"

"Um..."

"This is the doctor. I really want to know why my patients can not get their asthma inhalers when they need them. Why do they have to do without their medication until their doctor can talk to an insurance rep? Can I talk to your supervisor?"

Ten minutes of holding and no supervisor came to the phone. While waiting for the supervisor that never appeared, I looked up the drugs in question. My drug handbook listed all the albuterol inhalers as being interchangeable. I gave up waiting and I called a pharmacist. "Are Pro-Air, Ventolin, Proventil Inhalers and generic albuterol inhalers all the same thing?"

"Yes, they are," said the pharmacist.

"If one was not in stock could you substitute another as long as the prescription did not specify name brand only?"

"Yes, I could."

Very strange indeed. So, basically, my asthmatic patients on Medicare had been forced to do without their rescue inhalers until their insurer could fax my office a worthless piece of paper that my nurse showed to me the next day that I was in the office--meaning potential refill delays of up to 72 hours. How does that keep my patients healthy? It doesn't. Instead, it scares them. Anyone who has asthma knows how bad it feels to need your inhaler and not have one.

In what kind of country is it legal for someone's insurance company to deny them a necessary medication for 72 hours for absolutely no reason? A crazy country. Why would an insurer want to do this? That's easy. Scare your sickest patients enough and they will drop off your Medicare plan and sign up for a different Medicare plan. Since Medicare Advantage plans are paid a flat fee by the federal government for each enrollee, they have an incentive to keep healthy people happy with bicycle socials and sick people scared by denying them their medications. And it is working. People with the biggest burden of chronic illness are the ones most likely to drop off a so called Medicare Advantage Plan and back onto traditional Medicare, meaning that the tax payer picks up their bills while the privates collect premiums--and then pay themselves for denying services and benefits (the Q&A loophole).

This is not an isolated incident and it is not confined to a single Medicare Advantage Plan. See my old diaries for other examples. This fragmented Medicare is ruining the best insurance plan in the country---and, in the process, making it even less likely that we will ever see a single payer insurance plan since the privates can point to the mess they have made of Medicare---siphoning all the money off and leaving all the debt for the public to pay---and say "See? See? Single payer is too expensive."

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Arrow 32 replies Author Time Post
Reply Managed Care Denies Coverage for Generic Albuterol, Will Only Cover----Name Brand Albuterol (Original post)
McCamy Taylor Mar 2014 OP
Warpy Mar 2014 #1
DesertFlower Mar 2014 #27
jsr Mar 2014 #30
LiberalEsto Mar 2014 #2
pansypoo53219 Mar 2014 #17
LiberalEsto Mar 2014 #31
laundry_queen Mar 2014 #26
Cleita Mar 2014 #3
magical thyme Mar 2014 #4
DesertFlower Mar 2014 #29
silvershadow Mar 2014 #5
awoke_in_2003 Mar 2014 #10
bemildred Mar 2014 #6
Curmudgeoness Mar 2014 #7
LuvNewcastle Mar 2014 #8
Hoyt Mar 2014 #9
XemaSab Mar 2014 #19
Hoyt Mar 2014 #23
Le Taz Hot Mar 2014 #25
McCamy Taylor Mar 2014 #32
seattledo Mar 2014 #11
lostincalifornia Mar 2014 #12
Rebl Mar 2014 #15
MuseRider Mar 2014 #16
lostincalifornia Mar 2014 #21
Rebl Mar 2014 #13
Brickbat Mar 2014 #14
Hoyt Mar 2014 #18
nomorenomore08 Mar 2014 #20
Yo_Mama Mar 2014 #22
DeSwiss Mar 2014 #24
DesertFlower Mar 2014 #28

Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 06:00 PM

1. No shit, it's why Part D was such a complete scam

because it favored brand name drugs over brand X and had no mechanism for taking bids on medications to assure the best quality at the lowest cost.

It was a giveaway to Big Pill.

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Response to Warpy (Reply #1)

Sun Mar 9, 2014, 05:44 AM

27. exactly. nt

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Response to Warpy (Reply #1)

Sun Mar 9, 2014, 08:04 AM

30. The no-negotiation clause is Exhibit A.

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 06:12 PM

2. I had problems getting my inhalers this year

 

Our "insurance" as we laughingly call it, refused to cover Flo-Vent, which I've used for years.

Of the three inhaler brands they did cover, two contain lactose, and I'm lactose intolerant. The third one, for some unknown reason, cost far more than the others, but that's what I had to get in order to breath during the spring pollen season. And they wouldn't send me a 3 months' supply, just two inhalers.

We had to pay several hundred dollars for the two inhalers, because this year the so-called insurance has a huge deductible.

I can't figure out what's going on.

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Response to LiberalEsto (Reply #2)

Sat Mar 8, 2014, 09:10 PM

17. local honey cured my sinus hay fever. i wonder if it would help asthma.

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Response to pansypoo53219 (Reply #17)

Sun Mar 9, 2014, 11:43 AM

31. I can't see how

 

The tree pollen that affects me comes the earliest blooming trees, maple and juniper. These are followed by birch, oak, etc. Bees don't emerge until later, so they wouldn't be making honey from these wind-borne pollens.

For great info on your local pollen levels from day to day, check this link:

http://www.pollen.com/allergy-weather-forecast.asp

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Response to LiberalEsto (Reply #2)

Sun Mar 9, 2014, 05:02 AM

26. Hm

flo-vent is basically an inhaled steroid. There are a bunch of new ones on the market that are a combination of inhaled steroid and long-lasting bronchodilator. My doctors have been prescribing me those ones instead of flo-vent (maybe they are phasing it out?)...and then my usual rescue inhaler (ventolin). Maybe that's why the insurance companies are refusing to cover flo-vent...maybe they get some kind of kickback from the drug companies for refusing to cover it so that some other inhaler is prescribed and people pay more out of pocket for it. I don't know...they've all become so crooked it's hard to understand why they'd refuse to cover flo-vent.

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 06:14 PM

3. Yep. Noticed that myself. When I had to pay for it, I got

generic. Now that I have Med. D, I get Ventolin, which I believe costs three times more.

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 06:18 PM

4. k&r for the health care insurance scammers. nt

 

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Response to magical thyme (Reply #4)

Sun Mar 9, 2014, 05:59 AM

29. don't get me started. they have no business

being in the health care industry. my doc says we should have single payer.

let's face it -- special interests are very powerful.

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 06:50 PM

5. Healthcare is still a family plan. And by family, I mean Corleone. nt

 

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Response to silvershadow (Reply #5)

Sat Mar 8, 2014, 07:58 PM

10. Even the Corleones had some scruples. nt

 

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 06:55 PM

6. They are hoping some patients/physicians will give up, so they don't have to pay.

From that point of view, this probably works just great.

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 07:10 PM

7. And when the single payer deniers point to the mess

we have to shout it out.....the problems are coming from the for-profit companies. Private insurance only interested in profits is the real problem here.

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 07:48 PM

8. I'm going through that shit with my Part D provider.

I switched Part D providers this year because costs for my old plan were going up and the Medicare site gave this new company a higher rating than the old one. We're just getting into March now, and so far they've said they won't pay for 3 of my prescriptions. The latest one was Omeprazole, a common drug for acid reflux. But when my doctor changed it to Nexium, a much more expensive drug, there was no problem. I pointed this out to my pharmacist, who told me that I should see the Medicaid patients. Medicaid will ONLY pay for brand-name prescriptions now, no generics. She said that has her steamed, because the taxpayers are paying far more than they should have to pay to treat the Medicaid patients. I guess that's what happens when Big Pharma helps write the health insurance legislation.

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 07:54 PM

9. Not insurers' fault, generic albuterol does not exist now because of CFC ban to save ozone layer.

Well, there is some dispute whether pharmaceutical companies took advantage of situation.

But, it does not appear to be insurers' fault this time.

http://www.scientificamerican.com/article/unlikely-victims-of-banning-cfcs/

http://www.motherjones.com/kevin-drum/2013/10/heres-why-your-asthma-inhaler-costs-so-damn-much


While I'm sure there are abuses by Medicare Advantage Plans and straight Part D(rug) plans, as one who paid for my late mom's Rx drugs, I can tell you that the Medicare Drug Program is a big help to the elderly who either went without, or cut pills in half or thirds to get by before prescription drug coverage was enacted in 2005.

And, yes, I occasionally have to use inhalers and have to pay the patent co-pay. In June, I will be on Medicare.

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Response to Hoyt (Reply #9)

Sat Mar 8, 2014, 09:38 PM

19. Ventolin costs $5 in Mexico and $65 here

Why is that?

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Response to XemaSab (Reply #19)

Sat Mar 8, 2014, 10:12 PM

23. That's pharmaceutical companies charging what they can get away with here vs. poorer countries.

There are some other reasons, but that is the main one with respect to Mexico. Candian drugs are not as cheap as Mexico, but they are less than hrre because Canadians are not as well off as Americans and Canada's government maintains a tight drug formulary forcing drug companies to lower prices. In addition, as we see in this thread, a lot of us aren't willing to do what other countries do to contain costs. Folks here have a tough time accepting a tight drug formulary that is necessary to achieve lower prices.

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Response to XemaSab (Reply #19)

Sun Mar 9, 2014, 04:49 AM

25. Yes, thank you.

I used to go down to Mexico to get my asthma medication at a fraction of what it costs here. Tragically, it's just not safe to go to Mexico anymore.

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Response to Hoyt (Reply #9)

Sun Mar 9, 2014, 04:29 PM

32. Price of albuterol is another important issue. My concern is denial of payment

for a product that the insurance is going to cover sooner or later---and in the case of albuterol, "later" can be bad.

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 08:00 PM

11. Generics don't work as well for me.

 

I think this is the wrong focus of the argument. The nongeneric works better so that is what we should be fighting for.

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Response to seattledo (Reply #11)

Sat Mar 8, 2014, 08:18 PM

12. Actually we should fight for coverage for both. There is no question that even though generics are

supposed to be actively equivalent, that is not always the case with some people. Example, SynThyroid, a lot of the psych tropics, some blood pressure medicines, etc.

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Response to lostincalifornia (Reply #12)

Sat Mar 8, 2014, 08:46 PM

15. I agree

with you on that. My mother takes a drug that there is a generic form of, but her doc won't allow her to take it because it doesn't work as well. I guess what works for some, doesn't always work for others.

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Response to lostincalifornia (Reply #12)

Sat Mar 8, 2014, 08:52 PM

16. Agreed.

I take generic when I can. I am narcoleptic. I was started on Ritalin 32 years ago and use the same prescription as I did then. I have tried all the other drugs and none of them seem to work. Generic Ritalin is not effective for me, not at all. If I am to be driving, and I have to since my husband has a seizure disorder and we live in the country, then I must have a drug that works. My new ACA plan does not cover it at all, only generics. It is damned expensive. I make it last as long as I can. If I don't have to drive I don't take it as much as I am supposed to. At least that is not life threatening.

My brother just got out of the hospital with Respiratory Failure. He is very ill. His prescription for his inhaler was $300+. They knew he had no insurance after being in the ICU for 2 weeks and yet this is the prescription he was given from the hospital and then from the Doctor assigned to him when he got out. He can't do that. We do it for him for now. How in the hell did a small inhaler get to be so expensive? It cost less for me to give an inhaler to my horse than it did for my brother. Crazy shit.

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Response to MuseRider (Reply #16)

Sat Mar 8, 2014, 09:43 PM

21. There is a lot of things that need to be done, that is for sure

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Response to seattledo (Reply #11)

Sat Mar 8, 2014, 08:20 PM

13. I've taken

many generic scripts over the years and they've always worked just as well as the name brands.

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 08:20 PM

14. But at least we don't have the government getting between us and our doctors!

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Response to Brickbat (Reply #14)

Sat Mar 8, 2014, 09:33 PM

18. Yep, we ought to let them order MRIs, echos, labs, etc., on equipment they bought hoping

they could order enough tests -- many of them questionable - to pay it off in short time. Or, put patients on high cost drugs that are little better (if any) than older/cheaper drugs because the pretty drug rep offered doc bribes disquised as speaking/consulting fees, etc. Or, allow docs and hospitals to balance bill. And worse.

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 09:38 PM

20. I've had a similar experience, insurance paying for brand-names but not generics.

I figure they must be getting kickbacks from the manufacturer, to justify spending the extra $200 a month.

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Response to McCamy Taylor (Original post)

Sat Mar 8, 2014, 10:05 PM

22. Yup. It's true.

The Medicare paper chase is getting worse and worse.

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Response to McCamy Taylor (Original post)

Sun Mar 9, 2014, 12:49 AM

24. The corporations and their lobbyists run the government.

 

They write our laws.

They pay no taxes.

And they make us pay for everything.

Corruption can't be fixed.

Corruption can't be legislated away.

Corruption can't be policed away.

Corruption must be cut out.

- This is how it is.



K&R

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Response to McCamy Taylor (Original post)

Sun Mar 9, 2014, 05:57 AM

28. i have humana for part D. i was taking

carisoprodol (soma). they wanted my doc to fill out a special form saying he's qualified to prescribe it. it's a f------ g muscle relaxant. when i asked about flexeril (another muscle relaxant) i was told it wasn't covered. i said "what have you got against muscle relaxants"? you have no problem paying for my generic norco (hydrocodone 10-325) which is a narcotic.

fortunately i've just about weaned myself off the soma. it wasn't doing anything anyway. after a few years of taking these drugs they lose their effectiveness (at least they do with me) but we stay addicted.

by the way no problem with my clonazapan either. also in the process of weaning myself off that. been on it for 23 years. i could probably take 10 and wouldn't feel it. i was on 3 a few years ago -- now i'm down to 1/2 a pill.



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