Posts by swiftbear86

mellowcobra82 said:Can someone help me make sense of the difference between a primary care doctor at a community health center (like the "public" kind) and a private general practitioner? If I go to a private doctor, do I have to pay out of pocket for every single visit, referral, or prescription—even if I already have supplemental insurance? What exactly am I paying for at a private clinic? It’s all a bit confusing. 🤷

The main thing to look for is whether the doctor is in-network with Medicare. It doesn't actually matter if their office is part of a big community health center or just a small private practice; if they take Medicare, they're "in."

If you're seeing an in-network provider, your coverage should kick in and handle the costs.

Amanda Sanchez73 said:I’m not sure if I’m asking this in the right place, but if anyone knows, please help me out... up until now, my health insurance was registered in Fresno, but now I’m living in San Francisco. I’m married and my permanent address is here now... so I’m wondering, do I actually have to go all the way back to Fresno to de-register from my insurance, or can I just handle everything here in San Francisco?

Your question is a little bit fuzzy.

What exactly do you mean by "de-registering" from your health insurance?

Did your actual coverage or employment basis change?

Give me a little more detail about your current insurance status.

If you switched jobs, your new employer handles your enrollment with Medicare.

If you're talking about switching doctors, that's a completely different story.
Basically, you just pick a doctor near where you live who is accepting new patients. Once they confirm your registration with Medicare here in San Francisco, you're automatically taken off the list with your old doctor in Fresno.

If they’ve got a contract in place with that hospital, they just swipe your card right there on the spot. If not, you’ll have to pay upfront and then file a claim for reimbursement using the receipt issued in your name.

http://www.medicare.gov/in...dinacijama-u-p

http://www.aetna.com/in...eno-osiguranje

Here’s an article trying to make sense of Medicare's latest moves and how manufacturers and the American Pharmacists Association are pushing back.

Honestly, I’d be thrilled if Medicare finally gave doctors a heads-up when a drug is out of stock. It would save us from those endless debates with patients where they think we're just being difficult because we can't fill a prescription for something that isn't even on the shelves.

It would also be a huge help if they cleaned up the formulary—specifically by removing those weird packaging options (like a single pack of 60 tablets) that don't actually exist in the real world, yet stay on the list as a "cheaper" alternative to two 30-count packs.
Doctors are just trying to save people money, but instead, patients end up wandering around thinking we're either being stingy or just don't know how to do our jobs!

From what I can tell, there’s a promotion running over at Dosimeter.
The price of $25/month applies if you sign a three-year contract.

You linked to travel insurance—covering medical costs abroad—but supplemental insurance only covers treatment here in the States.
Basically, this CBO supplemental plan is offering way more value right now than Medicare!

Just take a look at the page right before that one; it explains everything clearly.

What kind of dental services would even need special negotiation??

Everything related to mandatory co-pays, prescriptions, referrals, or extra fees based on regulations is covered by the CBO supplement. It even handles those extra out-of-pocket costs for drugs on the extended list.

Quick heads-up for the parents here

After that initial period, you'll be covering the costs yourself.
Your best bet is to give your local Social Security Administration office a call—just find the one tied to where you live and ask them exactly what steps you need to take next.

From what I can see, you probably fall into this category at the end:
where you handle everything through independent payments.

I first set up this policy back on August 19, 2013, and my new card, contract, and payment slips for the upcoming year just arrived in the mail today.

Right now, these are pretty much the best terms you can find if you’re paying out of pocket $43/month, especially for those who don't have an extra prescription drug rider and end up picking up a few different medications every month that need to be covered separately.

There’s bound to be some competition coming, which should force Medicare to step up and offer a better deal—I actually think they might even have some kind of arrangement in place with the CDC.

Just check your user profile to see if the transaction status shows as completed.

vividsailor7 said:The whole "argument" boils down to one thing: the pharmacist refusing to fill the Rx. That's the bottom line.
As for the rest of this nonsense, it feels like nothing more than misleading the patient.
A specialist doesn't need to provide a warning label for every script; they prescribe the appropriate therapy, period. The pharmacist's job is to dispense it exactly as written.

It isn't about misleading patients; it's about following the official lists and Medicare guidelines.

The real question is why specialists aren't taking these issues to the drug commission to influence Medicare, rather than letting the hospital get penalized by having their budget slashed just because they didn't follow Medicare's specific rules.

After all, there are doctors sitting on that commission.

http://www.medicare.gov/guidelines

Felix - that's an excellent point you made at the end.
Once Medicare starts holding specialists accountable, things will actually start to change.

In my view, a patient should receive the best possible treatment based on medical standards. Specialists in certain fields should sit down with the commission and work it out, because right now, it feels like it's just a group of doctors who aren't even sticking to professional medical standards!!

vividsailor7 said:Why on earth shouldn't they be allowed to write the brand name??
Patients have every right to be pissed off because they were given medication based on professional guidelines, and they have a right to receive it at no cost.
As for why the American Medical Association is denying them—honestly, I should probably say it's none of my business, but lately, we’re constantly having to call out the AMA regarding medications. To make matters worse, they’ve become incredibly arrogant recently; for instance, they won't even listen if you tell them $167 you're spending a fortune on meds every month—they just don't give a damn about what happens down here.

We’re currently hitting the same topic across two different threads, so I’ll leave it to the moderator to decide which one stays active for the discussion.
I really don't get why there’s this constant friction between the AMA, the specialists, the patients, and the pharmacies.

My approach is always the same: I tell patients that the specialist prescribes the specific therapy they believe is best for the diagnosis. Then, the AMA has to figure out if they can authorize an Rx under Medicare or if they have to issue a private prescription, which means the patient pays full price out of pocket.

The tension would be a lot lower if specialists warned patients upfront. Sometimes people simply can't afford the medication, and when that happens, the entire treatment plan just goes down the drain.

So, does this mean Medicare is going to tell hospital specialists they have to write down the generic name, while leaving it up to the primary care doctor to decide which specific brand actually gets prescribed?

Otherwise, there’s just no point in specialists bothering with the brand names at all.

Right now, we’ve got a situation where specialists aren't even following the Medicare guidelines for prescribing therapy. It leaves the patient stuck in a loop—the doctor tells them they don't qualify for the recommended drug under Medicare coverage, so their only option is to pay full price out of pocket using a private prescription.
Take stuff like Plavix, Preductal, or Singulair, for example...

Thanks for sharing all these notes!

vividsailor7 said:

vilenjačica As I was saying:
If you ask me, this is just going to create an even bigger mess... I honestly can't make heads or tails of these new guidelines. It’s a total disaster—nothing makes any sense!Heading out to the outpatient clinic. So, the specialist ordered more testing just because he felt like it... what am I even supposed to do with that now? What kind of referral is he going to write me to make this actually useful? Honestly, I’m starting to think even my own doctor won't have a clue how to handle this mess. Hah!

Honestly, I have no idea why you people think you need to be experts on medical prescriptions. It’s not your job to decipher the fine print!
They’re going to issue you an outpatient referral, and honestly, I don't see what the big deal is. What part of that is unclear?

Jane—look, let’s get one thing straight. Avastin, just like all those other chemos, has absolutely nothing to do with my primary care doctor. These drugs aren't something you just pick up at a local pharmacy on a whim. They are administered in a hospital setting, fully covered by the hospital budget, specialized drug funds, or whatever specific insurance guideline is currently in play. My doctor couldn't prescribe this even if they wanted to! It’s strictly regulated. Because these medications are flagged for hospital administration only, that rule applies whether we're talking about tablets or IV infusions. Period.
What the hell am I going to say? I’ll tell you exactly what I think, and I mean this: if they have a properly signed medical history on file, then I don't give a damn about Medicare's guidelines or their ridiculous penalties. I truly do not care if they get slapped with a fine. I am prescribing medication based on professional medical standards—period. You and Medicare are the only ones treating patients this way anywhere in the world! If you follow those rigid little rules instead of actual medicine, a patient could literally die right in front of you because of it. It has this risk, it has that complication... I don't care. None of that matters to me. YOUR inspectors—you’re the ones who denied the patient their medication in the first place. Why even send it to an inspector if you're just going to block it? I CAN PROVIDE EXAMPLES.
The Cat, I’m sorry you had to deal with that (and I’m sure you weren't the only one), but I completely get why the patient reacted the way they did—not talking about any physical fighting, obviously—but you aren't giving them a drug that is CLEARLY INDICATED BY MEDICAL GUIDELINES. Once that happens, as far as I'm concerned, and 95 percent of SKZZ, the conversation ends right there. We've said our piece; from here on out, the responsibility for that patient lies squarely on your shoulders.

I agree that a specialist should prescribe based on medical standards, but they also have to keep Medicare guidelines in mind (since the healthcare facility is a contracted partner of Medicare). They need to explain to the patient upfront that for a specific diagnosis, Medicare won't cover it, meaning the patient will have to pay the full price themselves.

The guidelines for the Medicare drug list are located at the end of the list, where a code consisting of letters and numbers is decoded.

For example, the Plavix or Pigrel mentioned above are covered by Medicare for a period of 3 to 12 months following a procedure.

Guideline RB01
For treating patients after a bypass or stent placement, per the hospital specialist's recommendation, lasting from 3 up to a maximum of 12 months, depending on the type of stent.

Code ATK B01AC04 111

Brand name: Pigrel

Prescription Type: RS

Manufacturer:
Johnson & Johnson

Generic name - INN: clopidogrel

Method of administration: O

DDD and unit: 75 mg

Price per DDD / $: 5.31

Dosage form: film-coated tablets 28x75 mg

Price per unit without tax: 5.31

Price per unit with 5% tax: 5.58

Price for original packaging without tax: 148.78

Price for original packaging with 5% tax: 156.22

Price in $ without tax for single unit paid by the agency:

Price in $ with 5% tax for single unit paid by the agency:

Price in $ without tax for original pack paid by the agency:

Price in $ with 5% tax for original pack paid by the agency:

Co-pay in $ without tax paid by the agency:

Co-pay in $ with 5% tax paid by the agency:

Co-pay in $ without tax for original packaging:

Co-pay in $ with 5% tax for original packaging:

Main therapeutic group ATK: Drugs acting on the blood and blood-forming organs

Subgroup ATK: Platelet aggregation inhibitors (excluding heparin)

List: basic

NOTE indication / guideline: / RB01

To be honest, I'm really not sure—I just put it on my credit card.

So, I finally signed up for FDA coverage today, and I spent basically my entire afternoon just staring at my inbox waiting for a confirmation email.
It’s been total chaos over there—they aren't picking up the phone either, and I kept getting a busy signal every single time I tried to call.

edit
Well, the confirmation finally popped up after an eight-hour wait, which is funny because the coverage actually kicks in in just a few minutes.
If anyone else is out there stressing about the same thing, just hang tight. It’ll show up eventually.

Here’s a quick breakdown of how using your Medicare card actually works

Peter Perez66 said:I’d say calling this Medicare coverage—specifically the $43 part—"voluntary" is a joke, purely because we aren't forced to pay for it. But if you actually look at the classification and how the policy is structured, it’s clearly supplemental insurance. On the flip side, MetLife also claims to offer supplemental insurance, and honestly, it would be a miracle if they actually provided anything extra. I get mandatory coverage, but now we’ve got voluntary, additional, and supplemental thrown into the mix? I have no clue what actually exists, what the real differences are, or which of these two companies is actually providing what they claim... I'm legitimately lost here. I just want something that's "cheap but solid" 🙂. Basically, for $25 what I'm currently shelling out $43, I expect results. If it's not the same thing, the deal is off 🙂. It'll probably cost me more running all over town trying to find a pharmacy that actually works and chasing down receipts from these companies that rigged the whole system than whatever the price difference is anyway.

The root of the issue is that insurance agents don't explain things well enough to their clients, and clients really ought to do their own homework beforehand (though not everyone has the time or the knack for digging through websites).

I had an awkward encounter with a patient who hadn't been explained things properly, and she ended up making quite a scene at the pharmacy.
It took a lot of patience and tact to show her that she simply didn't have the right information.
She apologized later. 😉

Here’s the breakdown:

Medicare $43per month for those with higher salaries $1700
covers the co-pays for prescriptions, doctor visits, specialists, lab work, and hospital stays... but it doesn't cover the extra out-of-pocket cost for drugs that are on the specialty list
. Basically, you have to pay the difference yourself, and nobody is going to refund you .
If you use medications from that list, check here and run the math:

http://www.medicare.gov/specialty-drug-list

If you have FDA Supplemental Insurance then everything is covered , though you might not be able to apply it directly via your card at every single medical facility; sometimes you pay upfront and then file for reimbursement.
As for the co-pay $3.25per prescription, Medicare has an agreement with the FDA, so most pharmacies can process it easily. You just provide your info and you don't have to pay that $3.25.
But if there's a drug surcharge and the pharmacy doesn't have an agreement with the FDA, you'll end up paying the full amount, and you won't get that $3.25/prescription back immediately.

List of facilities

http://www.healthinsurance.gov/supplemental-coverage-info

Essentially, you get a full reimbursement for FDA Supplemental Insurance.

"Additional" insurance is something else entirely.
It grants you rights to specialist visits or herbal remedies covered by your specific policy.
There are various types of additional policies with different prices and service ranges. I think it's mostly geared toward people who want faster access to specialists or a bit more comfort during exams.

http://www.healthinsurance.gov/optima-plan-details

What's bothering both of us is where the catch lies 😕

I called the FDA and asked them what kind of sense it makes for an insurance company to offer this policy.$25/mo if a patient has to pay a copay for drugs on the supplemental list, say $100/mo (it happens).
The way I understood their response was that they're basically assuming people who don't spend anything at all end up with much more in their pockets. That’s just my take on what they said, though.😁

Bottom line for me? It’s a total no-brainer to go with the FDA plan, especially once you factor in the necessary reimbursements.
You get much broader coverage for $18 per month.
Look, I'm just not going to keep paying Medicare $43/mo.
My only real expectation is that they step up and offer a product that can actually compete with what the FDA provides.

If anyone has specific questions about how to actually use an FDA card, I’ve got a little energy left to answer them—even if I am currently gearing up for my summer vacation.😉

Just to be clear, I have zero ties to the FDA. This isn't an ad or anything; it's just observations from someone who works directly with patients and holds a contract with the FDA.

Jeremy Reyes4 said:How long does a prescription for orthopedic supplies actually last?
Is there a specific deadline for when you have to head to the pharmacy to pick everything up?

It’s valid for 30 days from the date it was issued.
Basically, if it's dated August 1st, that day doesn't count toward the window—you start counting from August 2nd. That means August 31st is the very last day the pharmacy can bill Medicare for it.
What this means in practice is that if you show up on August 31st and the pharmacy doesn't have what's listed on the script, or they can't get it in stock that same day, you're going to have to hunt down another pharmacy that does have it.
Once September 1st hits, that prescription is dead in the water.

For our regular patients, we can sometimes make an exception and release medication early in extreme circumstances—like yours—but we simply aren't allowed to process a prescription before its official start date.
Basically, we’re operating on a handshake basis here, trusting that you won't pick up the meds early and then try to grab them again once you arrive at your destination.

As for getting a brand-new prescription, you'll need to coordinate that directly with your doctor.