Stopping Evenity

Sorry...tried to delete this. I noticed to late that you've covered that.

Could you please explain this further? How are costs paid for a treatment covered by Medicare Part B different under an Advantage plan than under Original with a Supplement? I would think that Medicare's 'allowed amount' for the treatment charge would be the same...it is only the remaining 20% of the allowed amount that is handled differently.

It is basically not different except for out of pocket expenses … but what my specialist is doing now is no longer including medication in his bill to insurance but having the patient pay for the medication separately upfront. Cost is enormous without medical applied. What this means is that it uses up drug costs and at the same time does not allow for out of pocket costs which only applies to medical part B not drugs.

My question was addressed to a posting by@sueinmn about financial incentives for providers.

If my doctor was picking and choosing how to use my insurance coverage, I would contact the Medicare Rights Center to see if this is kosher.

I asked my insurance provider who indicated they can bill as they wish.

I would be reluctant to rely on anything said by an insurance provider.

Please consider consulting with either your State's Health Insurance (SHIP) program or the Medicare Rights Center, both of whom consider only your interests.

When you have an Advantage plan it is through an insurance company they receive a set amount per year for all of your Part B
care, based on a formula with some additions for preexisting conditions. If they spend less than Medicare gives them, they profit. If they spend more, they have a loss. The insurance company determines who their preferred providers are. If the doctor helps the insurance company keep costs low, they may get a bonus at the end of the year, spend too much and they get removed from the preferred provider list, so have fewer patients.

So the question becomes, is the doctor really looking out for patient's best interest or trying to help the insurance company cut costs?

Here is one thing you can do - look at the prescription drug formulary to see whether the drug is covered by Medicare Part B or Part D. That controls how the drug is to be dispensed and paid for.

Who knew getting older could be so complicated?

I did not ask anything about preferred providers but your explanation is not my understanding of PPO. So if you would share the source of your information, I would appreciate it.

My understanding of the consumer /patient benefit of a PPO is that referrals are not needed to see doctors who are otherwise in the insurers network. This is in contrast to an Advantage 'HMO' where the PCP must refer you to others for any services.

How PPO works in practice can be a bit of a mystery,

However, the point of my question had to do with whether it is kosher for a doctor who accepts an Advantage plan to then decide which part of an Advantage plan he prefers to use. I hope //think you are correct that that is NOT something the doctor decides. If Evenity is covered by Medicare Part B, then it does not seem the doctor can simply decide NO, you must procure the medication via Part D.

I guess this raises the question: can Evenity be procured/processed under either Part B or Part D?

The original poster seems to think there is much more out of her pocket when under Part D and that is why she is quitting treatment. I do not see how Part D, with its new $2000 cap, can be more expensive than Part B so someone needs to crunch the numbers with the original poster.

That is in part why I suggested she contact the SHIP in her state or the Medicare Rights Center....(along with the other reason about her doctor making such a decision about which Part he wants to use and the insurer saying that is OK.)

The way Medicare works in this country is an unpardonable sin....

Some drugs can be covered under either Part B or D - depending on the formulary. That's why I suggested she read it.
Preferred providers are determined by the insurers, who can drop them at will. And under a number of PPO Medicare plans, they concept is being used to DENY care outside the PPO, even if they don't have an appropriate specialist in network. It happens all the time with rare conditions-the insurers denies referrals to experts out of network and pushes patients back to their own preferred providers.
I just switched part D plans because the old one (an Advantage plan for Part D only) placed a medication in part d tier 3 (non-preferred name brand) in their formulary. It carried a high monthly copay. The new standard plan places it in part b or d as a tier 2 drug and allows the pharmacist to determine which costs me the least.

When a group of us on Medicare, taking the same injectable name brand medication, compared our copays in November, our costs ranged from $5 to $300 per month.