Dare I say something nice about my medical insurance company?

[NNadir]

I have Medicare Part C from the much despised (here) United Healthcare.

They recently approved a very expensive drug (evolocumab/Repatha) that I suspect will add a few years to my life. Of course, I have a rather large deductible for medications about two grand - which happily I can afford to pay, understanding that there are many people who can't - but it's April, and for the rest of the year, everything is free.

That's not, however, why I am here to praise the company.

I'm a chemist, but when I went to college, it was with the idea of becoming a pharmacist, since I was filling prescriptions as a kid (under the direction of a pharmacist) in high school. After my first chemistry class I recognized that I could already count to a hundred, and read a label and a script, so I switched to a chemistry major. I wanted interesting work.

Over the decades, I've been sort of mystified about why becoming a pharmacist requires so much education, when a clerk can do most of the job. In most cases, when I have discussed medicinal chemistry with pharmacists over the years, I've been disappointed, although my current regular pharmacist strikes me as a knowledgeable guy.

Yesterday, I got a call from United Healthcare and I took it. It was their pharmacist, United Healthcare's pharmacist, on the phone, who was calling to discuss a possible drug/drug interaction and to advise me on alternatives, one of which would involve higher costs for her company. The conversation was at a high level, and during it, I indicated that I would take her up on her offer to contact my doctor to suggest changing my drug from the generic to the branded compound still under patent. Although the copay (to meet the deductible) would be $72 for a month's supply, she noted that since Ozempic and now Evolocumab had eaten up the deductible, it wouldn't hurt to move to the newer small molecule drug.

I have not had an experience like this in a very long time, if ever, a pharmacist doing what she is trained to do, help me and my doctor choose a medicinal option. (When I was a kid working in a hospital pharmacy as a tech, my boss tried to do this, but was shot down by administration and the medical staff.)

I know this is probably not the place to praise an insurance company, and yes, I would rather live in a world with Medicare for all, but where praise is due, I am unashamed to give it.

Don't shoot me.

[Walleye]

1. Good for you giving credit where it is due. So many times we get screwed by crooks business

[RandySF]

2. I like mine as well.

[hlthe2b]

3. It is good to hear the good anecdotes as well. Not sure this represents change, but I hope...

[eppur_se_muova]

4. Meanwhile ... my Mom's insurance company is forcing her to buy Xarelto in $200 lots.

Last year, she was paying $45 for each 30-day refill. Not too bad. This year, she suddenly found the price had shot up -- $221, but it turned out that was for a 90-day refill. Whenever something like this has happened before, she has asked the pharmacist for a 30-day supply, which is more affordable. This time, the 30-day refill was over $100, so a 90-day supply would cost her over $300 -- closer to $330-340, IIRC. In other words, the price per pill was almost exactly 50% higher if she bought them 30 at a time than if she bought them 90 at a time. A pharmacist told me -- rather apologetically -- this was a new practice the insurers are forcing on everyone, because it saves them a little money to process 4 claims a year instead of 12 -- but $440 worth ?? She's on SS, so her income is limited and now she has to make sure she can afford to drop 10% of one month's benefit check on a single purchase, while still balancing all her other expenses. She has nothing left in savings at this point, and a backlog of car repairs ready to claim more than she gets from SS. So boo hiss for the insurer (Cigna), but thanks to the pharmacist who let us know about this.

[TBF]

6. I am still under private insurance and my Xarelto is cheap

but I have a savings card from the manufacturer. I've been on it over 10 years and always get 3 months at a time. It might be worth a call to the manufacturer to see if there's any program she might qualify for to bring the co-pay down.

[eppur_se_muova]

9. I've seen drug ads on TV mention those cards, but if I had ever seen one re Xarelto I'm sure I would have noticed !

Thanks for the suggestion, I'll give it a try.

[twodogsbarking]

11. Great advice. I have knownn others who did this successfully.

[TBF]

15. I'm pretty sure folks on Medicare wouldn't be included in their

private insurance pool, but I'm thinking they may have other "hardship" programs. It's worth a call, some of these meds can be so pricey.

[twodogsbarking]

21. Direct contact with the manufacturer is worth a shot. Learn all you can. Don't give up.

[LisaM]

22. That sounds as if it's on the manufacturer.

Processing three times as many claims per patient sounds like an administrative nightmare.

[RussBLib]

5. What about Part D?

My wife and I also have UHC for our Part C, but drugs usually come via Part D. She has been on Repatha for 2 years to lower cholesterol, and she made the mistake of going with Humana for Part D this year.

When she signed up via Open Enrollment this past fall, Repatha was on the Humana formulary. As soon as the new year rolls around, we are told by Humana that she no longer qualified for Repatha, since the FDA made some kind of change for the drug. Now her cholesterol is too low to qualify.

Appeal. Denied. 2nd appeal via the doc, denied. 3rd appeal, denied. UHC has had nothing to do with this issue. So I don’t understand why UHC, as your Part C provider, got involved in a drug issue.

https://russblib.blogspot.com/?m=1

[Ms. Toad]

24. Humana - and specifically CenterWell mail order pharmacy - is the worst.

My spouse and I shop Part D plans every year. This is the first year I've switched, but my spouse has switched every year. So we have lots of experience in the process of switching in February.

Normally, all of my existing meds appear as available for transfer. None of them did. I had to add each one (including the address, phone number, etc. for the prescriber since they are apparently building their prescriber database by customers adding doctors) and request a new prescription. 4 months into the year one of the 4 prescriptions we had not yet filled finally showed up to transfer. The other 3 are still MIA.

But to your experience, my spouse is on a standard dose of Potassium Citrate. (If you've never encountered it, it is the most wildly varying price I've ever found - from $140/year to $1500/year, depending on insurance plan). Humana added a new wrinkle. They will not fill her standard dose without special approval. We're probably just going to buy it from Costco (slightly more than $140/year, but not much).

Their rating at the BBB and other places is between 1 and 1.5 stars out of 4 or 5. I left a good long complaint, then read the others that had been posted and every single thing I complained about had already been complained about by several others. And 3 months later - the complaints are still pouring in.

[genxlib]

7. I have to admit

I have been pleasantly surprised that CIGNA/Caremark has decided to cover GLP1 medications for both me and my wife.

Neither of us is diabetic or even seriously obese. We just need a little extra help.

I was shocked but they approved without questions.

Credit where credit is due.

[TBF]

8. I've had good luck w/their Optum program, also,

for my specialty medication. I switched to them in January when I switched Rheumatologists. I think UH may be making Optum mandatory (or at least really pushing it), but I was willing to give it a try because the last pharmacy I had to use at a hospital was so unresponsive that I basically have nothing to lose. Optum has actually been wonderful - they have 24/7 phone assistance, and they were able to get my manufacturer savings card into their system quickly. I have to do that every year for a couple of my meds, but once it's in then it's big savings all year.

Nothing wrong with having a good experience, we have so much negative all the time that it's nice to see when something actually works well.

[Freddie]

27. I'm also very happy with Optum

Between husband and myself we have many prescriptions. We get refills quickly and cheap from Optum. Also have United Healthcare AARP Medicare Supplement. I’m on Mounjaro, it’s $178/month but way less than the retail price.

[Nanjeanne]

10. Medicare Part C is Medicare Advantage plan. Medicare A and B are original Medicare and Supplemental

Plans for Medicare(private insurance plans) are supplements to original Medicare A and B which cover things Medicare doesn’t and are a variety of plans that are run by private insurance(was the way Medicare was able to get passed and a giveaway to private insurance companies). Each plan is standardized within each A thru N plan but priced differently by different insurance companies and compete by price, quality of customer service etc. Part D are drug plans that are called Medicare drug plans but actually private insurance run (thanks Bush).

If you have a Plan C you have an Advantage plan thru UHC and if you have been satisfied with your plan, that’s great. It probably includes some drugs so you didn’t get a Medicare D plan. Glad it’s working out for your d hope it continues to give you the protection you need.

[radical noodle]

12. It's actually nice to hear something good for a change

I keep looking for the catch to everything now, but it sounds like this is a good deal for you. Congrats.

[edhopper]

13. But

should we really give them credit for doing what you are paying a hefty monthly premium to do?

"Insurance company does it's job!" should not be a headline.

[Zackzzzz]

14. I was prescribed a blood thinner after 2 afib events.

I went to my local RX and it was Very Expensive.
After 2 months, I found a much cheaper price on line, but the new pharmacist wouldn't fill it.
That sharp person read the small print, take 1/2 dose if under 130 lb and over the age 70.
That's me. So I was on double dose, twice a day for 2 months.
There's more to it,
But I am very Happy the Pharmacist caught what could have been life changing.

[Be The Light]

16. Your talents are being wasted

You should be a apothecary

An apothecary is historically a medical professional who formulates and dispenses materia medica (medicinal ingredients). Today, they function as pharmacists, herbalists, or specialists in natural health,, providing custom compounds, herbal remedies, and specialized wellness products like tinctures and essential oils.
Roles and Services

Formulating Medicines: Traditionally, they prepared drugs for physicians and patients, essentially acting as early pharmacists.
Retail and Wellness: Modern apothecaries (like Merz Apothecary) sell natural health products, organic skin care, niche fragrances, and supplements.
Custom Compounding: Specialists create personalized medication doses and formulations.
Herbal Consultation: Many, particularly those focusing on herbalism, advise on the use of plants for health

[DownriverDem]

17. Friend on regular Medicare

She was told to go with a Medicare Advantage Plan for 2026. She had been told to not go with a Medicare Advantage Plan in the past. When she asked why she was told that you never know what trump will do. I've been attacked here for going with a BCBS of Michigan Medicare Advantage PPO Plan every year since getting it.

[Rebl2]

18. My

Father in-law had something like an advantage plan. I believe it was a HMO. They took great care of his macular degeneration and other easy health needs. When he got lung cancer, it was like, how quick can we get rid of him. They never even suggested chemo to treat it. He was in his mid 70’s, and they just didn’t want to pay for it.

[AncientOfDays]

19. I like Kaiser

Kaiser Medicare Advantage. No big things to report about, but I think it operates like I think universal healthcare should. most of my medications have been in the $10 copay range, and recently been free, Vascular surgery inserting stents was something like $160.

For last year:
- Drugs
+ office visits
+ 3 procedures (vac surgery, cataract surgery, etc)
+ xrays/cat scans/ultrasounds
+ vaccinations
+ lab work
came to less than $1,000 for everything

[ananda]

20. My provider is also United Health.

This year has gone fine.

I don't know what will happen next year.

[Stargazer99]

23. I disagree with you as I am UHC and am forced to take statins which wreck my short term memory

I have constant inability to retrieve common words when talking to others. I lost 2 incidents totally with no memory at all (scares the hell out of me) some times it takes day to retrieve the word. Statins work through the brain and interrupt the communication between the cells in the brain. I have asked for Repatha which works through the stomach not the brain and I have had UHC DENY using Repatha instead of statins. I think it is because I am poor and screwing the low income is easy....I do not agree with your post

[NNadir]

25. I am not here to say that every case is praiseworthy. However, it is true that my case has some risk of fatality.

I may have been approved for evolocumab on a cost/benefit basis, that my elevated risk of stroke or heart failure may outweigh the costs of trying to prevent these since I decline to take statins anymore.

I stopped taking statins, after 20 or 30 years because I developed extreme muscular sensitivity.

In the past weeks, I have been evaluated for heart surgery, and for the time being, I'm home free but my reading of the literature suggests that it is quite possible my case will worsen. I'm not afraid of dying, since I will die one way or the other, as everyone will, but I would rather not be severely incapacitated.

I didn't ask for evolocumab; my doctor suggested it and submitted his reasons for the recommendation to UHC. I'd rather that medical cases were decided on merit rather than money, but it's not my call.

I note that I consider that my condition may have been exacerbated by my inability to get antibiotics fast enough to cure a case of strep I had in my twenties, in part because I had no car and no one to take me to a doctor. My poverty at the time played a role in this. This probably triggered, owing to my genome represented by my family history, an autoimmune disease known as rheumatic fever. It appears that a peptide sequence connected with immune response to streptococcus A matches a sequence in my particular HLA form, DRB1 DR5 on the 6th chromosome. For now I'm OK, and evolocumab may extend the time I live disease free.

It sounds to me that it is quite possible I'm better off financially than you may be, and quite possibly it plays a role in the difference in our access.

There seems to be some literature suggesting that statins may have neurological effects; the more I learn about lipidomics, the more I understand that lipids play a huge role in neurochemistry. Statins are drugs operating on the lipid system/

However, they are prophylactic drugs in general, not really treatments. They prevent disease; they do not cure it. They are fairly ineffective for LDH's, and it is LDH's that are involved with my condition, aortic stenosis.

It's very clear in these times there is an unjust discrepancy between those having financial resources and those lacking them.

None of this, of course, precludes me from offering praise for the interaction described. In my case, they did good, and again, I do not feel precluded from stating as much.

I am on record supporting Medicare for all, not just for me.

I know I am privileged and I regret that others do not have access to what I have. I regret you are unsatisfied.

I wish you good health. During open enrollment, you should shop around, at least for as long as Medicare exists at all. If it disappears, and it may owing to the orange pedophile, I will be screwed.

[xmas74]

26. Im a firm believer in giving credit where it's due

Some plans are better than others, though in the long term a public option would probably have the best coverage.

[FadedMullet]

28. Nice to hear your story and see that insurance companies can do good by their customers. In contacting you, they......

.......were speaking to a knowledgeable person who could understand and appreciate what they were offering, but I've got to think that that's not always the case. I wonder if they experience much push-back from other people along the lines of "don't mess with my medicine, my doctor says it's what I need."

[NNadir]

30. It is an unfortunate reality that the rigorous educations that pharmacists have is in most cases, underutilized.

I do know that there are research pharmacists, and I know a number of pharmacists who are executives, some at the C level, a pharmaceutical companies.

I actually don't believe that Doctors in many cases, are as aware of pharmacology as are pharmacists who have not forgotten what they learned in their educations.

Those educations should be treated with far more respect than they are in practice.

Unfortunately, if your day to day job involves counting pills and looking over the shoulders of techs to see that the label is correct, and taking calls from Doctor's offices, it is easy to forget that for which one has trained.

In my current medical adventure with aortic stenosis, after my testing, the group made a follow up appointment with a nurse practitioner who was good with cardiac anatomy, but who clearly did not understand etiology or pharmacology on a level I would have regarded as sufficiently well informed. She does have authority to write scripts. (For my next follow up, to see if the condition worsens to such a level as to require treatment, I'm changing groups and institutions, particularly because Penn medicine, a research institution, has an excellent reputation for valve replacement surgery, should I require it before dying from something else.

Our culture has elevated the physician, physicians assistant and/or nurse practitioner over pharmacists, which I think, in general is unwise. The inability to question physicians, to treat them like gods, is not good for patients, nor, in fact, for physicians themselves.

[FadedMullet]

29. NN - Just curious. How does "small molecule" fit into a discussion about picking an appropriate or effective Rx ?

[NNadir]

32. It doesn't, but I made a distinction between the two drugs mentioned in that sentence which were large molecules.

Evolocumab (Repatha) is a monoclonal antibody - a protein drug - and Ozempic is a large synthetic peptide.

[Skittles]

31. they are under a microscope right now

yup