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A rant!!! How much worse can goverment health care be than this scenario???

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A rant!!! How much worse can goverment health care be than this scenario???

Old 08-29-2009, 06:02 PM
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Angry A rant!!! How much worse can goverment health care be than this scenario???

My doctor wants me to take a pill every day (along with my other diabetes meds) I go to get the prescription filled with a coupon for a free months supply. I get the free month I am told that the doctor needs to file a pre-authorization with the insurance company. He does, I go today to have my prescription filled they give me 7 pills. Now the prescription clearly states 1 a day for 30 days with 3 refills. The pharmacist tells me to call my insurance company. They tell me that they are authorized to give me 7 pills every 30 days. Now I am not a math genius but even I know you can not take 7 pills and make them last for 30 days if you take 1 a day.
Now the insurance company who handles the prescription drugs tells me to contact my primary insurance carrier. Because they are only authorized for 7 pills in 30 days. I now need to write a letter to my primary carrier explaining that the prescription was for a pill a day (forever) and they need to authorize additional quantity coverage. WTF!!!!
Sounds like we already have government run health care.. or is it "catch 22"?
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Old 08-29-2009, 06:19 PM
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Unfreakinbelievable!

and no one will step up to help, it's pass the patient to the next person!
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Old 08-29-2009, 06:32 PM
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You can have government run health care or you can have privately run for-profit health care.

Which do you want?
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Old 08-29-2009, 06:39 PM
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privately run for-profit health care
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Old 08-29-2009, 06:39 PM
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Sorry to hear it but I am afraid this is just the beginning. Its a train wreck.
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Old 08-29-2009, 06:42 PM
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I saw this and I'm certain I won't be the last to chime in but here is a true story from my family's perspective.

My 87yo grandfather lost his leg in WWII, he receives VA care and Medicare. The VA provides (some) of his prescription meds free. However you have to be on your toes and mail the prescription in, early in the case of refills, wait for the meds to arrive (sometimes a month or more) and then double check them to see they are the correct drug, dosage, and pill count in the bottle since sometimes they will just mail the original manufacturers bottle.

That's bad enough but here is where the government bureaucrats really loose my confidence. If it's a prescription NOT on the VA approved list he has to get it at the pharmacy, but Medicare will refuse to pick up the extra cost because he has coverage under the VA even though the VA won't provide that specific drug. VA says we don't have it so he doesn't get it from us, Medicare says we won't pay for it because the VA SHOULD, let me repeat the governments words for the slower left leaning readers, "the VA SHOULD provide those meds to him" even though they don't.

Government has had 2 bites at the apple to provide coverage to it's neediest citizens and still can't get that right. We don't need a third non-functioning layer of government run healthcare. Your frustration is understandable, but it will only get worse and become the blanket coverage for all if the government begins stepping over private industry.
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Old 08-29-2009, 06:45 PM
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If you think Uncle Sam is going to do a better job you are sadly mistaken
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Old 08-29-2009, 06:46 PM
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Originally Posted by TR/X View Post
I saw this and I'm certain I won't be the last to chime in but here is a true story from my family's perspective.

My 87yo grandfather lost his leg in WWII, he receives VA care and Medicare. The VA provides (some) of his prescription meds free. However you have to be on your toes and mail the prescription in, early in the case of refills, wait for the meds to arrive (sometimes a month or more) and then double check them to see they are the correct drug, dosage, and pill count in the bottle since sometimes they will just mail the original manufacturers bottle.

That's bad enough but here is where the government bureaucrats really loose my confidence. If it's a prescription NOT on the VA approved list he has to get it at the pharmacy, but Medicare will refuse to pick up the extra cost because he has coverage under the VA even though the VA won't provide that specific drug. VA says we don't have it so he doesn't get it from us, Medicare says we won't pay for it because the VA SHOULD, let me repeat the governments words for the slower left leaning readers, "the VA SHOULD provide those meds to him" even though they don't.

Government has had 2 bites at the apple to provide coverage to it's neediest citizens and still can't get that right. We don't need a third non-functioning layer of government run healthcare. Your frustration is understandable, but it will only get worse and become the blanket coverage for all if the government begins stepping over private industry.

There are all kinds of Private Insurance nightmare stories out there. If you haven't heard them then you are not paying attention.
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Old 08-29-2009, 06:52 PM
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Don't forget - it's all the fault of the Big Pharm companies and Big Medical Device companies.

The government have been telling you that for a decade, and hounding these companies out of the country just to prove to you that they are on top of things!

Except the cost of products are a small part of the pie - and actualy the more efficient and innovative part. But I guess the good ol' American voter feels better when R&D spending goes to India while hospital and other adminstration costs soar.

Frankly, we deserve what we get.
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Old 08-29-2009, 06:56 PM
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Frankly, we deserve what we get.


Couldn't agree more. I think we should let our healthcare system choke this country to its knees. Maybe then we'll get serious.
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Old 08-29-2009, 07:05 PM
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The FDA is the governing body over pharma companies. In a very large way, they are responsible for the exceptional costs incurred for development and approval of new medicines. The other half of the story is the *_)(*^(*%^ BS lawyers that sue just because.

The FDA is a government body.
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Old 08-29-2009, 07:07 PM
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and I might add the most highly regulated industry in the world. So you see its the kettle calling the pot black
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Old 08-29-2009, 07:38 PM
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Originally Posted by Barry Turano View Post
My doctor wants me to take a pill every day (along with my other diabetes meds) I go to get the prescription filled with a coupon for a free months supply. I get the free month I am told that the doctor needs to file a pre-authorization with the insurance company. He does, I go today to have my prescription filled they give me 7 pills. Now the prescription clearly states 1 a day for 30 days with 3 refills. The pharmacist tells me to call my insurance company. They tell me that they are authorized to give me 7 pills every 30 days. Now I am not a math genius but even I know you can not take 7 pills and make them last for 30 days if you take 1 a day.
Now the insurance company who handles the prescription drugs tells me to contact my primary insurance carrier. Because they are only authorized for 7 pills in 30 days. I now need to write a letter to my primary carrier explaining that the prescription was for a pill a day (forever) and they need to authorize additional quantity coverage. WTF!!!!
Sounds like we already have government run health care.. or is it "catch 22"?
Good post Barry. This points out a number of issues.

1. The previous poster correctly points out that heath care in the United States is the most heavily government regulated industry bar none. This is most certainly true, and not a political opinion. Everyone in the medical, dental, pharmacutical, and hospital industry agrees.

2. This means, we already have government health care, with most all of the mandates to be carried out by the "private" sector.

3. You are attempting to get some "free" pills. It appears you physician has acted in your interest by helping you with the script, and helping you "authorize" filling the script. When the government is paying the physician, and he only derives his pay/salary from the government, he/she may have less ardor to help and retain patients since he will no longer have the self interest in a "private" practice. I've seen this first hand in VA physicians. They go home and leave problems to the "on call" physicians. "Why not? I'm not on call?" Shameful, but inevtiable.

4. Nobody says that insurance companies are particulary "patient oriented." Life insurance companies, auto, Prop/Casualty etc. All insurance companies only are money vehicles. They want your money, and wish to pay out the minimum defined by their "contract" with the insured. Health insurance companies are no different. The government health insurance plans are precisely the same. (Medicare/Medicaid/CHIP etc) Except the government plans withhold from the physicians and hospitals. The government only want your premium money and your taxes. Your insurance company is placing barriers to skimp on the payout as much as they can. The pharmacy wants to get paid, and they get their funds from the insurance company so they are stuck in the middle.

5. Simple solution. Pay for the prescription yourself. This takes the insurance company out of it. The pharmacy will gladly accept your cash, and the time wasted is down to the minimum.

6. Lastly, I'm confused about the 7 pills situation. Would that be seven pills each refill until you have received 30 free pills? Or is it your impression that the insurance company is only springing for seven pills and that's it? If your coupon says one thing, and the company another, that's cause for a visit to the courthouse and contract law. You can force the company to honor their contract, but waste all your time.

7. In a government single payor system you won't find any relief in contract law. It's like suing city hall. You'll never win. As pointed out, the government (VA/Medicare etc) makes absolute decision of all kinds of "approved" medicines. If it's not "approved" you pay out of your own pocket.

I certainly understand your frustrations with the current state of things. I only urge extreme caution in comparing this "mess' to a solution that will be far far worse.
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Old 08-29-2009, 07:54 PM
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Originally Posted by TripleCrownNC View Post
The FDA is the governing body over pharma companies. In a very large way, they are responsible for the exceptional costs incurred for development and approval of new medicines. The other half of the story is the *_)(*^(*%^ BS lawyers that sue just because.

The FDA is a government body.
Actually they are not.

They approve new products and enforce follow-up trials and recalls etc.

Regulatory bodies for these companies include, FDA, OIG, NIH, Senate Finance Committee, Senate Committee on Aging, DOJ, and that is just at the federal level. Add in the unique laws of every state in the union, plus foreign bodies and you DO HAVE the most regulated industry in the world.

And most of those regulations have costs that the companies are asked to carry. Guess what happens to those costs - yep, passed on to the end consumer just like any other product costs.

So ask yourselves, why does a Pharm or Medical Device company have to follow a federal statute and then 51 other state level statutes that look to doing the same thing? And pay fees to all while doing so?

The American voter is being blindsided, obvious by the politicizing of the current effort for reform.

Start off by identifying the root causes and deal with those first. Then see if you still have an issue.
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Old 08-30-2009, 05:12 AM
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Originally Posted by dssmith View Post
Good post Barry. This points out a number of issues....



5. Simple solution. Pay for the prescription yourself. This takes the insurance company out of it. The pharmacy will gladly accept your cash, and the time wasted is down to the minimum.
BINGO!!!!!!!!!!!!!!!!!!!!!!!!!!!!

It is medical insurance, not a lifetime maintenance plan. Until people fully understand what it is and what it is for, no one will ever be satisfied with the services provided. I am not saying that the cost of medical treatment is or is not justified, but people need to understand the basics of how insurance works rather than thinking they deserve the lowest premium but the greatest benefits. The numbers just do not work and the numbers will never work as long as medical treatments are added and people are living longer.
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Old 08-30-2009, 05:47 AM
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Old 08-30-2009, 05:49 AM
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Originally Posted by dssmith View Post

The previous poster correctly points out that heath care in the United States is the most heavily government regulated industry bar none. This is most certainly true, and not a political opinion. ...

Well, maybe it's a tad bit of a political opinion you have there. I think nuclear energy is the most heavily regulated industry. Health care and pharma are full of backdoors and loopholes, hence all of the fraud and deception therein.
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Old 08-30-2009, 06:46 AM
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Default Maybe I did not explain myself correctly.

Maybe I did not explain myself correctly.
1. The free pills were a trial from the manufacturer.

2. The prescription is for 1 pill a day per month.

3. The prescription was authorized by the doctor to the Prescription Drug part of the insurance company. They in turn authorized it's use. No one said that they will only pay for 7 pills every 30 days and the balance is not covered.

4. The Prescription Drug part of the insurance company now says that the Primary part of the insurance company needs to authorize the additional quantity of medication every month.

5. Simple math 1 pill a day = 30 pills per month. Insurance allows 7 pills $14.06/2=$7.03 per pill. Balance of 30 day supply 23 pills (without insurance) $814.62/30= $35.42 per pill. According to the Prescription drug plan a 30 day supply will cost me $30.06 co-pay (if authorized by the primary carrier) If on my own with my $14.06 co-pay and my out lay it will cost me $828.68 per month.
If this does not get settled soon it will be internet sales to: PharmaceuticalCompanyinIndia.com (or some other supplier)

I agree that government run health insurance is not the answer. But is this situation far from it?
I am not looking for something for nothing. I do not like the bureaucratic BS and being bounced around from one department to another within the same organization. By the way when I finally got to a person wha took the time to explain about getting another authorization, guess where he was?
Hint his name was Raj.






Originally Posted by dssmith View Post
Good post Barry. This points out a number of issues.

1. The previous poster correctly points out that heath care in the United States is the most heavily government regulated industry bar none. This is most certainly true, and not a political opinion. Everyone in the medical, dental, pharmacutical, and hospital industry agrees.

2. This means, we already have government health care, with most all of the mandates to be carried out by the "private" sector.

3. You are attempting to get some "free" pills. It appears you physician has acted in your interest by helping you with the script, and helping you "authorize" filling the script. When the government is paying the physician, and he only derives his pay/salary from the government, he/she may have less ardor to help and retain patients since he will no longer have the self interest in a "private" practice. I've seen this first hand in VA physicians. They go home and leave problems to the "on call" physicians. "Why not? I'm not on call?" Shameful, but inevtiable.

4. Nobody says that insurance companies are particulary "patient oriented." Life insurance companies, auto, Prop/Casualty etc. All insurance companies only are money vehicles. They want your money, and wish to pay out the minimum defined by their "contract" with the insured. Health insurance companies are no different. The government health insurance plans are precisely the same. (Medicare/Medicaid/CHIP etc) Except the government plans withhold from the physicians and hospitals. The government only want your premium money and your taxes. Your insurance company is placing barriers to skimp on the payout as much as they can. The pharmacy wants to get paid, and they get their funds from the insurance company so they are stuck in the middle.

5. Simple solution. Pay for the prescription yourself. This takes the insurance company out of it. The pharmacy will gladly accept your cash, and the time wasted is down to the minimum.

6. Lastly, I'm confused about the 7 pills situation. Would that be seven pills each refill until you have received 30 free pills? Or is it your impression that the insurance company is only springing for seven pills and that's it? If your coupon says one thing, and the company another, that's cause for a visit to the courthouse and contract law. You can force the company to honor their contract, but waste all your time.

7. In a government single payor system you won't find any relief in contract law. It's like suing city hall. You'll never win. As pointed out, the government (VA/Medicare etc) makes absolute decision of all kinds of "approved" medicines. If it's not "approved" you pay out of your own pocket.

I certainly understand your frustrations with the current state of things. I only urge extreme caution in comparing this "mess' to a solution that will be far far worse.
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Old 08-30-2009, 07:19 AM
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To make a long story short: we changed Rx plan recently and now have higher co pay and higher deduc. I went to fill a 30 day Rx for Allegra. Cost with co-pay was $ 118 or thereabouts. Co-pay used to be $ 20 or $ 30. But our skyrocketing group cost was prohibiting keeping that plan. My dad, a retired MD said to look into the cost from Canada. Same drug, same qty was $ 39. So I know where I will refill next time.

From a small business owner standpoint it is more cost effective to nowadays just have a higher deductable, basically for catastrophic health events and pay the cost of drugs out of pocket. As for MD visits, I bet most would negotiate a price benefitting them and the patient. But I'm sure gov will put a stop to that (remember Hilary care, she didn't want MDs doing that). Of course this would not work for hypochondriacs and people that over medicate.
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Old 08-30-2009, 07:59 AM
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Originally Posted by Barry Turano View Post
My doctor wants me to take a pill every day (along with my other diabetes meds) I go to get the prescription filled with a coupon for a free months supply. I get the free month I am told that the doctor needs to file a pre-authorization with the insurance company. He does, I go today to have my prescription filled they give me 7 pills. Now the prescription clearly states 1 a day for 30 days with 3 refills. The pharmacist tells me to call my insurance company. They tell me that they are authorized to give me 7 pills every 30 days. Now I am not a math genius but even I know you can not take 7 pills and make them last for 30 days if you take 1 a day.
Now the insurance company who handles the prescription drugs tells me to contact my primary insurance carrier. Because they are only authorized for 7 pills in 30 days. I now need to write a letter to my primary carrier explaining that the prescription was for a pill a day (forever) and they need to authorize additional quantity coverage. WTF!!!!
Sounds like we already have government run health care.. or is it "catch 22"?
Who is your primary insurance carrier? Did you not give the pharmacy your primary insurance information when you got your RX filled?

Billing and even authorization is a nightmare when it comes to COB (coordination of benefits). Best to make sure the pharmacy and your doctor both have ALL of your insurance information.

Believe it or not.... a lot of payors are not just paying claims for all medications anymore... they have some meds that require prior authorization. So what SHOULD have happened.... is your prescribing doctor should have submitted the RX Auth request through your PRIMARY insurance company. Once approved they return the Approved Auth to your doctor and that's that. In other words.... the RX process is becoming much like the approval process for other services and procedures in healthcare.

The problem is that doctors can't know what every company's prior Authorization requirements are by heart.... so s/he was probably unaware yours required a pre-authorization.

Another thing.... does your Primary Insurance Company offer a Disease Management Program for Diabetes? If they do, enroll PRONTO! Yes, you will have to fill out an enrollment questionnaire... but typically these programs offer patients lots of free stuff.... AND you get a Nurse Case Manager who manages your case.... you can call the nurse when you have problems such as this with your meds and they will get the ball rolling to straighten the mess out. This nurse is your contact on the "inside" .... they know the system and how to get through the red tape. They also care about you the patient and are your advocate.

Good luck.
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