Study Shows Part D Plans Ratcheting Up Restrictions on Coverage

[sman]

No doubt, roughly 70% of chronic conditions are self induced (lifestyle, diet, etc.) Probably similar numbers for cancer, heart disease.

And many of those conditions can be modified or reversed with changes.

Like you, I see a lot of folks with multiple meds, especially mental health related (anxiety, depression).

Many conditions are not self induced, genetic or caused by environmental situations.

And I often shake my head but also realize too many prefer to take a medication vs making lifestyle changes.

I also have a number of clients with arthritis and other types of inflammation caused pain. In another 30 years or so, you may be in the same boat. Just sayin'

So don't cast stones . . .

The medical community should take some of the blame. Personal experience here. Not long after I turned 40 I thought I should probably have my cholesterol checked. I have two uncles who had heart issues. Granted, they are both very overweight and smoked. You've seen me, I'm nowhere near overweight. I'm a fit guy. I'm active and eat fairly well.

Anyway, my cholesterol test revealed my cholesterol was very high (307 total cholesterol). HDL was good, but LDL was high. The doc immediately prescribed a statin. I told her, "let's wait on that...maybe I did this to myself and can undo it". I made some minor changes and went back two months later and it was down to 264. I was with Kaiser at the time and received an email from the doc and she said she just realized I never got the prescription filled and I needed to start taking it.

I replied back with my same comment above and told her I had made some minor changes and it came down some. I'll make some additional changes and hopefully get it down more. She replied saying that it was impossible for me to get it down from that level without medication. I replied with the following two words:

Challenge Accepted

Two months later when I had it checked, total cholesterol was down to 225 and LDL was in normal range.

She emailed me and said "whatever you are doing, keep doing it".

The answer for many doctors is to grab the prescription pad.

What I also discovered in my research is our bodies generate about 80% of the cholesterol and we control the other 20% through diet, exercise and other outside factors such as stress. My body just generates more than average so I have to work extra hard to keep it down.

But people are to blame as well. I was sharing the above story with a friend and he kinda laughed and said he just takes a pill for it so he doesn't have to watch what he eats or do much exercise.

The pharmaceutical industry has done a good job of training the masses and buying the docs and politicians.

 

[somarco]

You & Rachel have similar issues. Her cholesterol is 300+ but the "good" cholesterol is outstanding.

So far is bypassing the Rx. Diet and exercise has always been good. She takes red yeast rice (a natural statin) and another supplement (don't recall which) . . . otherwise her numbers would probably be 400+

She has lab work 2x per year to make sure everything is working.

 

[renee15]

A new study from University of Southern California (USC) researchers shows that Medicare Part D plans have been increasingly restricting access to some prescription drugs through the years. Plans have used prior authorization, step therapy, and formulary restrictions to curb beneficiaries’ ability to take certain important prescriptions. The study covered 10 years, from 2011 to 2020, and showed plan adoption of each of these utilization management practices steadily gaining traction.

Plans can exclude some drugs from their formularies entirely, meaning enrollees either must pay out of pocket or try to get an exception by submitting an appeal to the plan. In 2011, plans excluded 20.4% of drugs. By 2020, that number was up to 30.4%, with an even higher 44.7% for brand-name drugs.

Even if drugs are on the formulary, plans can limit access. For example, prior authorization requires prescribers to get plan permission before it will cover a drug, and step therapy requires patients to use one or more other drugs before gaining access to the prescribed drug. In 2011, plans subjected 11.5% of drugs to prior authorization or step-therapy restrictions. By 2020, that number had reached 14%, with a higher 23.7% for brand-name drugs.

[EXTERNAL LINK] - Study Shows Part D Plans Ratcheting Up Restrictions on Coverage - Medicare Rights Center

So as a new Medicare member a few months ago.-Generic drug T2 in Dec covered I paid $0 G-Caremark(MEDDADV) or Aetna paid $35.20. First refill in 2024-$280 deductible. Same RX. I was charged $196.78. How could the carrier pay 1/6 that amount in December? They are screwing insureds

 

[GoPokes]

The medical community should take some of the blame. Personal experience here. Not long after I turned 40 I thought I should probably have my cholesterol checked. I have two uncles who had heart issues. Granted, they are both very overweight and smoked. You've seen me, I'm nowhere near overweight. I'm a fit guy. I'm active and eat fairly well.

Anyway, my cholesterol test revealed my cholesterol was very high (307 total cholesterol). HDL was good, but LDL was high. The doc immediately prescribed a statin. I told her, "let's wait on that...maybe I did this to myself and can undo it". I made some minor changes and went back two months later and it was down to 264. I was with Kaiser at the time and received an email from the doc and she said she just realized I never got the prescription filled and I needed to start taking it.

I replied back with my same comment above and told her I had made some minor changes and it came down some. I'll make some additional changes and hopefully get it down more. She replied saying that it was impossible for me to get it down from that level without medication. I replied with the following two words:

Challenge Accepted

Two months later when I had it checked, total cholesterol was down to 225 and LDL was in normal range.

She emailed me and said "whatever you are doing, keep doing it".

The answer for many doctors is to grab the prescription pad.

What I also discovered in my research is our bodies generate about 80% of the cholesterol and we control the other 20% through diet, exercise and other outside factors such as stress. My body just generates more than average so I have to work extra hard to keep it down.

But people are to blame as well. I was sharing the above story with a friend and he kinda laughed and said he just takes a pill for it so he doesn't have to watch what he eats or do much exercise.

The pharmaceutical industry has done a good job of training the masses and buying the docs and politicians.

I recently had a similar experience. Last August, at age 38, I had an annual, and my cholesterol levels were too high. (Even higher than 12 months prior when they were high).

Doctor said if it didnt improve in 6 months, id be on a statin. I have no history of cholesterol with either parents. In fact neither of them take any maintenance meds

I grabbed a notepad and pen, asked him what foods I needed to cut down or avoid. I looked at the list, and realized I certainly consumed too much of the wrong items.

Exercise was already a part of my lifestyle. So, I cut out a lot of the items, and cut back on the others. I restarted intermittent fasting.

The fasting made me realize that there is a tendency in our culture to eat more than necessary. To eat when we feel hungry. We dont actually need to eat when we think we need to eat, and of course we often dont eat the right things when we do.

It worked. I lost 20 pounds, and the HDL dropped from 240 to 170, and the LDL from 168 to 99.

As a tangent, to the over consumption of food in our culture. I think it's interesting how many other issues could be alleviated. As you think about how much resources go into the production, shipping, and storage of the excess food (not to mention the stuff that doesnt even get sold). If we could simply eat less, it would solve a lot of issues.

 

[Northshore]

You comment "From all appearances, many PDP carriers are in the market for the sole purpose of converting policyholders to more profitable MAPD plans." hits home. The attempts by the carriers to poach our Medicare clients seems to be accelerating. I signed up for a dental discount card with dpbrokers.com and, after a year, was contacted by them trying to get me to go to a Medicare Advantage plan through them. I won't ever promote their dental plan again.