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Joinfortmill

(16,989 posts)
Fri Jan 10, 2025, 12:17 PM Jan 10

About Medicare Advantage plans, frustrated doctors, and an old gal who has changed her mind

Full disclosure: I've always had a MA plan and I never had a single issue regarding coverage or denial of service or medications. I've gone through cataract surgery and two brain stents for for a brain aneurysm that costs thousands of dollars. Then in 2024 I ran into this:

I developed Geographic Atrophy, better known as 'Wet' Age Related Macular Degeneration (AMD), which is characterized by the growth of unnecessary , damaged, blood vessels that leak blood and fluid into the eye, causing central vision loss. The most common treatment is ongoing eye injections (yup, a shot into the eyeball) that temporarily stop the proliferation of these rogue blood vessels.

There are three or four different medications (most of these medications are anti-cancer drugs (It gets complicated) that are injected into the eye at a cost of $50 to $2000 per injection. The $50 shot works sometimes. The higher priced medications work all the time.

So, this is what my Retina Specialist (who is DISGUSTED) with MA plans told me today after I had my 4th shot in four months. Because one of the previous three shots was not the lowest cost drug, but a sample he used, it did not meet their 'requirement' that three shots of the lowest cost drug be used AND is shown not to be working before they will approve the higher priced drugs.

So, there you have it. The physician cannot provide the best, most appropriate medication for a disease that could well cost me my central vision. So, after ten years of coverage with an MA plan, I am going to enroll in original Medicare as soon as I meet a qualifying event.

I don't know what the moral of this story is. All I know is the decisions these health insurers are making are not based on sound medical advise, but on saving a few hundred dollars at the risk of human lives and the loss of payments directly from Medicare, because you can't get blood from a stone or dollars from a dead old gal.

34 replies = new reply since forum marked as read
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About Medicare Advantage plans, frustrated doctors, and an old gal who has changed her mind (Original Post) Joinfortmill Jan 10 OP
Trump and his cronies gab13by13 Jan 10 #1
If that happens things are gonna get much worse Joinfortmill Jan 10 #5
We all need to be aware that the insurance companies would not be so aggressive, nor spend so much, on marketing Attilatheblond Jan 10 #2
Absolutely! SheltieLover Jan 22 #28
Please explain the 'qualifying event' you mentioned EYESORE 9001 Jan 10 #3
If my MA is not offered in my State next year Joinfortmill Jan 10 #7
Medicare Advantage djtexas Jan 10 #4
There are exceptions. Joinfortmill Jan 10 #8
You can always get back on Medicare dpibel Jan 10 #16
This is true. I will likely pay more and/or Joinfortmill Jan 10 #17
Similar problem for FIL with ELIQUIS...he may have to rely on $2k a year cap JT45242 Jan 10 #6
Not sure if your FIL qualifies gab13by13 Jan 10 #12
Thanks...he tried that JT45242 Jan 10 #14
Honestly, I don't think any healthcare system can handle using the most expensive drugs when cheaper ones Silent Type Jan 10 #9
I have no issue with a drug that works... Joinfortmill Jan 10 #10
Totally agree once it's clear cheaper med isn't working. I just don't support going to the most expensive first because Silent Type Jan 10 #11
Best of luck. Joinfortmill Jan 10 #13
Often they make you try cheaper even if it is contraindicated JT45242 Jan 10 #15
Wishing you a good outcome. Joinfortmill Jan 10 #18
By accident we found a slightly longer duration between shots helped my mom IbogaProject Jan 11 #19
3 Drs warned me about MA XanaDUer2 Jan 13 #20
We have much bigger concerns than this Zombie2090 Jan 21 #21
That was unnecessarily rude. Joinfortmill Jan 21 #22
welcome to DU. B.See Jan 22 #24
@ op, the Medicare advantage plans have B.See Jan 22 #23
It's much easier to get a medigap plan if you've Joinfortmill Jan 22 #25
Have you tried to switch to standard Medicare? SheltieLover Jan 22 #26
Thank you. Soon, I hope. Joinfortmill Jan 22 #27
Not sure if it's by state or what, by Farm Bureau gap ins SheltieLover Jan 22 #29
You are very kind. I'll follow up with a post when Joinfortmill Jan 22 #30
I'll be watching for it. SheltieLover Jan 22 #31
Many of us have tried to warn people here of the problems with MA. Voltaire2 Jan 22 #32
Guess it depends somewhat on B.See Jan 22 #34
Advantage plans have always been a profit-making scam. Lonestarblue Jan 22 #33

Attilatheblond

(4,969 posts)
2. We all need to be aware that the insurance companies would not be so aggressive, nor spend so much, on marketing
Fri Jan 10, 2025, 12:23 PM
Jan 10

if they didn't stand to make a LOT of profit on these policies. And the way they make the profits is by denying coverage.

EYESORE 9001

(27,737 posts)
3. Please explain the 'qualifying event' you mentioned
Fri Jan 10, 2025, 12:26 PM
Jan 10

I haven’t had occasion to butt heads with my MA provider yet. I haven’t switched over to regular Medicare totally, as it would require paying a monthly premium, and I’m a cheap bastage. Still, I prefer not negotiating with a death panel composed of hospital administrators and corporate bean-counters.

Joinfortmill

(16,989 posts)
7. If my MA is not offered in my State next year
Fri Jan 10, 2025, 12:38 PM
Jan 10

Which may well happen. It's happened often to me in the past, I'll switch.

djtexas

(36 posts)
4. Medicare Advantage
Fri Jan 10, 2025, 12:32 PM
Jan 10

You may not be eligible for original Medicare.

I think it is an unfortunate restriction (in the fine print) that if you enroll in a Medicare Advantage plan that you can never get original Medicare.

Please report back what you find out.

dpibel

(3,487 posts)
16. You can always get back on Medicare
Fri Jan 10, 2025, 01:40 PM
Jan 10

The problem is that you may not be able to get a supplemental plan, or may have to pay through the nose for one.

Without a supplement (which is, for all the wailing about Advantage, private insurance), you're on the hook for 20%.

JT45242

(3,074 posts)
6. Similar problem for FIL with ELIQUIS...he may have to rely on $2k a year cap
Fri Jan 10, 2025, 12:38 PM
Jan 10

Regular medicare D it is between $50-60 a month.

Medicare advantage put it on name brand formulary and you must show other generic blood thinners didn't work.

His best option is to try to quit his advantage and go back on regular medicare part D or just suck it up and pay $400 a month until his prescription total for the year hits $2000 thanks to Biden.

It is so hard for me to not say..you voted for the felon three times. Reap what you sow.

gab13by13

(26,001 posts)
12. Not sure if your FIL qualifies
Fri Jan 10, 2025, 01:07 PM
Jan 10

but it is worth a phone call. I was paying 400 dollars for a 90 day supply of Eliquis and now I am paying 10 dollars a month. It has nothing to do with income, it is a program done through Bristol Myers Squibb.

Call this number to find out about eligibility

1-855-ELIQUIS - 1-855-354-7847.

JT45242

(3,074 posts)
14. Thanks...he tried that
Fri Jan 10, 2025, 01:09 PM
Jan 10

Got two months cheap and is no longer eligible.

Big cluster f....

Wife called me last night. Asked me try to find a solution.

I do appreciate the helpful link...

Silent Type

(7,880 posts)
9. Honestly, I don't think any healthcare system can handle using the most expensive drugs when cheaper ones
Fri Jan 10, 2025, 12:50 PM
Jan 10

work well the vast majority of time.

Medicare -- what we consider the model for universal healthcare -- has coverage requirements for treating macular degeneration too.

I'm at high risk of macular degeneration. If it gets to that point, I'll try the cheaper med that is like $100 to see how it works just because it makes sense. Other folks will rush to the expensive, heavily advertised meds.

Joinfortmill

(16,989 posts)
10. I have no issue with a drug that works...
Fri Jan 10, 2025, 12:57 PM
Jan 10

In my case, my condition is worsening and They're denying medication that would be effective.

Silent Type

(7,880 posts)
11. Totally agree once it's clear cheaper med isn't working. I just don't support going to the most expensive first because
Fri Jan 10, 2025, 01:01 PM
Jan 10

some doctor -- who probably is invested in companies that make the more expensive drugs -- recommends it.

I hope your treatment is successful, the little blurry spots get annoying after awhile especially when they get bigger.

JT45242

(3,074 posts)
15. Often they make you try cheaper even if it is contraindicated
Fri Jan 10, 2025, 01:12 PM
Jan 10

All the cheaper drugs that my FIL should have to step up through to get the new name brand have potential major problems with one of the many other cancer or other meds he is on.

IbogaProject

(3,978 posts)
19. By accident we found a slightly longer duration between shots helped my mom
Sat Jan 11, 2025, 12:28 PM
Jan 11

We were doing every 6 weeks and once when delayed to 8 weeks the condition improved. Not sure if her's was wet or dry. But yes, MA plans have profit seeking and those delays in care are often dangerous.

XanaDUer2

(14,961 posts)
20. 3 Drs warned me about MA
Mon Jan 13, 2025, 05:31 PM
Jan 13

And said choose traditional M. I can't afford a supplement. I may look into that. I'm hoping to get a small pension in 8 mos.

I'm sorry. Id b pissed. My thought s are Republicans want to end TM move everyone to MA and start cutting benefits. So i don't want it.

I hope your ok

Zombie2090

(1 post)
21. We have much bigger concerns than this
Tue Jan 21, 2025, 06:45 PM
Jan 21

I recommend that we start making fireside chats like FDR. We are now, just like Germany in the 1930s, in a country that voted away its rights. I recommend that we have fireside chats like the one I created on AI for free. But done much more professionally for each day of the occupation.



B.See

(4,210 posts)
23. @ op, the Medicare advantage plans have
Wed Jan 22, 2025, 08:44 AM
Jan 22

turned to shit, including my own Aetna PPO where maximum out of pocket expense has tripled.

Don't quite know what u mean by qualifying event, but I THINK you can switch from a MA plan to a regular Medicare plan (or to another MA) ANYTIME before the end of March.

SheltieLover

(61,291 posts)
29. Not sure if it's by state or what, by Farm Bureau gap ins
Wed Jan 22, 2025, 09:11 AM
Jan 22

Was the chespest for me by hundreds of dollars per month.

Is there a manufacturer discount program you could use?

Call your local Council on Aging & ask if there is an organization who can help to defray costs.

I hate that you are going through this & would gladly cover the cost for you if I could. Vision is nothing to play around with.

I hope you find a solution soon!

Joinfortmill

(16,989 posts)
30. You are very kind. I'll follow up with a post when
Wed Jan 22, 2025, 09:17 AM
Jan 22

I make the transition to traditional medicare.

Voltaire2

(15,082 posts)
32. Many of us have tried to warn people here of the problems with MA.
Wed Jan 22, 2025, 09:50 AM
Jan 22

But a lot of people are happy with their shitty dental plans and their shitty vision plans and the gym memberships they never use, and they haven't been denied coverage yet, so they stay on MA.

Getting off MA is difficult as you can be discriminated against by medigap plans for pre-existing conditions.

The whole system needs to be reformed, ACA, Medicare and Medicaid all need to be combined in a single universal comprehensive public health insurance system.

Perhaps after the fascists finish wrecking everything we can put it back together the right way.

B.See

(4,210 posts)
34. Guess it depends somewhat on
Wed Jan 22, 2025, 07:15 PM
Jan 22

what each person's particular needs are. As with all plans, one size doesnt fit all.

Lonestarblue

(12,162 posts)
33. Advantage plans have always been a profit-making scam.
Wed Jan 22, 2025, 10:20 AM
Jan 22

Because they now hold over 50% of the Medicare market, the insurance companies are more blatant about maximizing their profits and minimizing medical care through denials of coverage.

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