Managed Care Denies Coverage for Generic Albuterol, Will Only Cover----Name Brand Albuterol [View all]

[McCamy Taylor]

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."