Medicare: It’s better than nothing


I am extremely fortunate to be as healthy as I am at my age, considering I’m a champion couch potato and computer addict. My health care consists primarily of semi-annual doctor check-ups, some routine annual tests, and a fistful of prescriptions (knock wood). It’s that last part that really has me po’d right now.

Medicare Part D. The prescription “coverage.” What a joke. I’ve been thinking I like the HMO I’m with. They have real live people — polite, friendly people — answering their phones and my questions. Turns out they can afford to be friendly.

They send out quarterly statements of what they’ve paid on prescriptions. Nice, I thought. Detailed breakdown of every script filled, name, date, amount, how much it cost, how much they paid, how much I paid, and totals. I dutifully tuck it away somewhere in case I need it for reference, taxes, or whatever. (I developed a severe allergy to numbers in my childhood, and if I don’t keep my exposures brief, my head starts to swim and my eyes cross.)

Okay, bottom line. You’ve heard of the “doughnut hole,” right? I have initial coverage up to a total of $2700; then the infamous doughnut hole kicks in, and until my total costs reach $4073.13, I have no drug coverage. Period. (I have absolutely no idea where they came up with those numbers.) I live in fear of the $2700 mark and the doughnut hole. I watch those totals like a hawk, guesstimating whether I’ll stay under $2700 for the year.

What I was overlooking until a few days ago was that when my pharmacy submits a claim on one of those $4 generic scripts, the HMO pays $0, zilch, nada, yet still counts it as $4 toward that $2700! Doh. How stupid am I. (That is a rhetorical question, which means you, dear reader, aren’t supposed to answer it!)

Several more scripts caught my attention. A whole 65 cents paid on a $9.65 refill. $7.06 paid on a $47.06 script. Except for the generous payments on the eye drops I have to use, I might as well not have prescription coverage. But of course I keep paying the premium because one of these days I’ll probably need what amounts to catastrophic coverage.

Ever friendly, this HMO sends out a nice little quarterly newsletter chock full of helpful articles on maintaining good health, keeping medical costs down, etc. The last issue had a little item on the front page headlined “How to Save Money on Your Prescriptions.”

It started off saying the $4 generic prescriptions are a great savings opportunity for members! (The exclamation mark is theirs.) Then it says it’s very important to instruct the pharmacy to bill these claims to them. Why? Because if we the members pay cash for these prescriptions (which we do anyway), the HMO’s data will not show that we’re taking that drug and the cost of that drug “will not accrue toward any deductibles, and medication reviews for cost savings or therapeutic suggestions will not be accurate.”

Furgit that! Sorry, dear HMO, but if you aren’t helping me pay for these drugs, it’s none of your damn business. My pharmacist, my doctor, and I have a good grasp of both savings and therapeutic suggestions. You are not a participant here; you are a third party. You can and do choose what you will pay for, but the decisions are ultimately mine, not yours.

Nor does some Medicare pharmacist in Washington need to feel responsible for my “medication therapy management” or need to have “all of the information” to help me “manage” my drug regimen. I have a doctor, thank you very much. And I have a very competent pharmacist who keeps track of everything I take and warns me of any possible adverse reactions or interactions (on the off chance the doctor might have overlooked something).

You, dear HMO/Medicare, are an insurance company. Nothing more. You do not dictate my medical care. You do not make my medical decisions. Your job is to help me pay for the health care I choose. And so far, you’re doing a pretty mediocre job of that.

... and that's my two cents