If you are a caregiver and familiar with the administrative horror show that is Medicare Part D, you can save yourself the 10 minutes you would ordinarily spend on this space. If you are not, you will be glad you invested the time, because inevitably, you will find yourself fighting with an insurance company while racing the clock. Trust me, you want to avoid learning this stuff on the fly because those 2 things just go together.
On their 65th birthdays, seniors in the U.S. get access to Medicare. It’s actually a few different programs, which vary from great to “huh?” The great part is Part A, which is basically comprehensive medical insurance that helps cover inpatient care in hospitals, as well as skilled nursing facility, hospice, and home health care. Then there’s Part B, which pays for services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition. It also helps pay for lift recliners and a variety of other stuff that is advertised on cable channels during showings of old movies. Smart marketing.
Ideally, your parent has supplemental coverage on top of Medicare. This is extra insurance that covers things that Medicare won’t under Parts A, B and D. Especially for Part D.
The big gap in Medicare until about 10 years ago was in prescription drug coverage. While you were in the hospital, medication is covered, but the minute you busted out (more on this in another post), you were on the hook. Along came the mid-2000’s Republican Congress looking to cement elderly voters as leaning GOP, and Medicare Part D was born.
Part D should be better than it is. It’s totally run by third-party insurance companies so is not the single payer model that Medicare is. Sometimes these are the same carriers who have your separate long-term care insurance policy. Sometimes your father knows the difference. Most time he doesn’t, can’t explain it to you, and stashed the policy information deep in a drawer somewhere. I’m just saying. Plus it’s different in every state, so when you move, it can’t move with you.
When my father was discharged from the rehab center where he spent almost a month recuperating after his C-Diff-inspired hospital stay, his Vancomycin regimen became our responsibility. Like most Americans, I have spent a decent part of my adult life on antibiotics, so when I got the prescription from his rehab center medical group, it seemed like a lay-up. I even placed an order for takeout Chinese food from my dad’s favorite place near the CVS.
It was a muggy, rainy night in New Jersey and after placing our order and informing the nice man behind the counter that I’d be back in 15 minutes, I went into CVS holding the prescription.
“OK, I found the medication,” the pharmacist told me. “But do you know that this medication is $3,000?”
“What? How can that be?”
“Well, it’s a Level 5 drug and the doctor didn’t get a Prior Authorization . Also, the prescription is for liquid but we only have capsules. For liquid you need to go to a compounding pharmacy.”
I understood none of this. That morning I had woken up naively believing that springing my father from rehab would be a good idea.
It tuns out that a compounding pharmacy is one that mixes medications from certain compounds in a variety of forms. Good enough. So eventually I got into my dad’s car and drove to the nearest compounding pharmacy, which was in a low rent strip center in Hamilton, NJ. To find it, I had to rely on Google Maps on my cellphone, which drained the battery to nearly, but not quite zero. There I told the pharmacist my tale of woe. He looked up the medication. Still a Level 5 drug. Still no prior authorization. Still $3,000.
He was able to figure out for me who I should call (AARP Insurance, my dad’s supplemental carrier), what information I needed, and what tactics I should use to overcome the inevitable denial that was coming (“tell them he’ll end up back in the hospital without it,” he said).
He also let me borrow the phone at the counter because of my aforementioned cellphone battery issues. This worked great until I’d been on the phone for more than 30 minutes, after which point he and the other staff members kept reminding me impatiently that I’d taken up one of the only 2 phone lines in the store. After 45 minutes, they told me that I had to get off. I honestly thought I was closing in on success, so kept pushing them off. (I was wrong, but didn’t know it).
After an hour, a woman behind the counter hung up my call, and then as I freaked out because I (wrongly) was convinced that I was about to break through, denied that she had done it.
If you are an experienced caregiver, you know this story. You have grown accustomed to feelings of powerlessness. Whether dealing with advancing age, health conditions, or insurance bureaucracies, you have come to accept feelings of inadequacy that stem from the situation, not from anything innate. This was my first brush with it with my emotional guard down, and as I stood outside the compounding pharmacy on a muggy, rainy, August night, I was shocked.
As an added bonus, my cellphone battery had now completely drained, so I had no way of calling my father to explain why my 30 minute CVS errand was now taking almost 5 times as long.
The ending: I called the doctor’s office once I got home that night, and told their answering service that yes, it was an emergency even though their policies said that they couldn’t alert doctors for prescription questions. I finally got the “Prior Authorization”, and got them to change the prescription to pills instead of capsules. My father got his Vancomycin dose a few hours late, but at least it was the same day. I wrote down all of the phone numbers, insurance plan numbers, etc. and put them into a document that my brother and I share online. The medication didn’t cost $3000 — but the out-of-pocket was almost $800. Part D coverage is different for different medication types at different “levels” based on which version of the plan you’ve signed up for.
In terms of dinner: the Chinese food was cold and soggy when I got it, and microwaving the Kung Pao Chicken did not help the situation much. Then I drank 2 beers when I finally got home. Strong ones. Quickly.
The moral of the story is this: find out all of your parents’ Medicare Part D coverage information BEFORE you need to know it, and always remember that anything besides the standard medications likely will require additional authorizations that only your doctor can get. And above all, do not order Chinese food before picking up complex medications. You are tempting fate, and as caregiver, this almost never works.