KFF Report on MAPD Prior Authorization

[goillini52]

Somarco uses fear and no first hand knowledge when discrediting Mapd . My mapd active is near 1000. YET TO THIS DAY IVE NEVER GOT ONE CLIENT THATS TOLD ME A PROCEDURE HAS BEEN DENIED .Now admittingly I’ve not been doing 2 1/2 yrs .Sure ive gotten some clients who had to appeal first denials but ultimately got the procedure done . Even on very expensive drugs .Most mapd carriers have clinical pharmacy fax #’s for rx exclusion lists to appeal Bottom line is most carriers have approved drugs not on their formulary when appealed

My wife had to get a PA on an expensive drug on a SS stand alone PDP. $47 a month is much better than $542.

 

[Packerland]

Could this be part of the reason some refuse to give their clients all their options? Too much of a hassle for only $601.00?

Actually it's $25.01 monthly after year one..

Regardless you are correct... People that refuse to get certified to sell PDP's or MA's are either lazy, not willing to educate themselves, not willing to have c m s oversight and or just happy selling one product.

I know i'm preaching the choir...

Education is your friend

 

[LostDollar]

Caveat, not an agent.

I would think for the first 65 years of our lives we were also in plans that required prior authorization. In NJ the MAPD plan is a lot better than the plan I was paying $915 a month for. If someone can afford the $915 a month plus the $3000 deductible, I am pretty sure they can afford the $6700 maximum out of pocket. MAPD's are not for everyone, but neither are Med Supps. In 15 years while some people complained to me about the prior authorizations, no one has told me their procedure was not approved.

I would think for the first 65 years of our lives we were also in plans that required prior authorization.

Just because we were in those plans does not necessarily mean we liked them or found them to be the most effective way we could have received our medical care.

If someone can afford the $915 a month plus the $3000 deductible, I am pretty sure they can afford the $6700 maximum out of pocket.

Paying under duress is NOT the same thing as affording.

 

[goillini52]

Not unexpected, but a number of ANECDOTAL responses. How about evidentiary citations to support your theory? Bueller?

We're not happy with my wife's Cardiologist (takes 4 months to get an appointment), so I called another one. They wouldn't see her without a referral from her PCP. After they got the referral, which also showed what insurance she has, they called to schedule an appointment that's only 2 weeks out. She asked me if they were in Aetna's network. I had to tell her twice that since it's a Med Supp, there is no network.

That's one of the things I like about a Med Supp. If you're not happy with a Specialist or medical group you can fire their ass. We've fired 2 Cardiologists, a Pulmonolgist, a PCP a medical group and a hospital.

I might be lazy as far as not wanting to hassle with MA problems, but I do take the AHIP and am certified with 3 carriers.

 

[somarco]

I would think for the first 65 years of our lives we were also in plans that required prior authorization. I

Managed care was not widespread until the late 80's in most parts of the country, so your guesstimate is off by 30 years or so.

Thanks for playing. We have a nice parting gift for you to take home.

 

[somarco]

My wife had to get a PA on an expensive drug on a SS stand alone PDP. $47 a month is much better than $542.

PA or formulary exception?

The PDP may balk at a non-formulary drug, such as Eliquis, but will usually make an exception with a note from the provider.

For Eliquis (and many other drugs) you can get it for a lesser price than full retail when ordering from Canada.
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Generic slightly cheaper . . .
[EXTERNAL LINK] - Discount Eliquis Apixaban Medication Price | Buy Eliquis 5 mg, 2.5 mg


PA is virtually unheard of with PDP.

She asked me if they were in Aetna's network. I had to tell her twice that since it's a Med Supp, there is no network.

Just one of the reasons I tell clients to just say they have OM and don't mention the Medigap. Too many front office staff are quick to say "we don't take that plan", or "we are not in their network".

KISS and it is much easier. Usually the only other hassle is the front office asking for your Medicare card and insurance carrier card. I tell them I don't have my Medigap card on me because no one asks for it. I am never denied service, or told to go home and get it. Sometimes they tell me to bring it the next time.

Which of course I never do . . .

 

[somarco]

I often wonder if those who heavily promote MAPD plans are too lazy to learn how Medicare in pure form really works, too weak to ask a prospect for a premium check, or just plain greedy.

 

[goillini52]

PA or formulary exception?

PA

 

[somarco]

PA

That's unusual . . . haven't run into that before on a PDP

 

[sman]

That's unusual . . . haven't run into that before on a PDP

There are medications that have PA. Look through any carriers formulary and you’ll see PA listed next to some meds. Even for common medications like Zolpidem.