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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....
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As for the Part B vs Part D drug cost differences, many Medicare plans have either zero or very low copay for Part B expenses, and each copay counts towards their out-of-pocket total for the year. Part D,on the other hand, carries its own copay that count towards the $2000 cap but not the out-of-pocket limit. That extra $2000 expenditure can mean the difference between being able to cover expenses or doing without to many people.
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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.