Today’s In Retirement post gets a little personal so be forewarned.
It involves erectile dysfunction (which I don’t have) and an enlarged prostate (which I do).
Neither are uncommon for people my age.
Let me take a step back and mention that as part of my teacher retirement pension benefit I am offered a subsidized Medicare Advantage plan to enroll in.
I’m not exactly forced to enroll in an MA, but the subsidy makes it hard to turn down.
The thing is that the government gives MA plans (not Medicare) the right of pre-approval for certain procedures and medications, regardless of what my medical team may prescribe.
On January 1st Illinois teacher retirees were switched from United Healthcare to Aetna’s MA.
The good news is that, for the time being, our premiums have gone way down.
The bad news is that according to a study by Kaiser Health News, Aetna has one of the highest denial rates of any of the major MA plans.
The denial rate ranged from 3% for Anthem and Humana to 12% for CVS (Aetna) and Kaiser Permanente, KHN found. The share of denials that were appealed was almost twice as high for CVS (20%) and Cigna (19%) than average (11%). While a substantially lower share (1%) of Kaiser Permanente denials were appealed.
Recently diagnosed with Crohn’s Disease, a form of Irritable Bowel Disease (IBD), I was prescribed a biologic drug treatment of Entyvio. I receive the infusion treatment monthly.
The retail price of Entyvio is $7,000 a dose. It is administered by IV and takes about a half hour.
United Healthcare required pre-authorization, which they gave. When we were switched to Aetna I had to request pre-authorization again, which Aetna gave five days before my next scheduled infusion.
By the way, stress is a trigger for a Crohn’s flare up. Waiting for pre-authorization up to almost the last minute was stressful.
I needed pre-authorization again recently when after a visit with my medical team I was given a prescription to help reduce the size of my prostate (no cancer!).
My doctor prescribed the drug to try an avoid surgery.
But the drug is known as tadalafiL as a generic. You may have seen it advertised on TV as Cialis. It is most commonly used to treat erectile dysfunction.
My doctor prescribed one dose each day. But Aetna denied coverage because they will only cover six a month for erectile dysfunction.
But I don’t have erectile dysfunction and the drug was being prescribed for something else.
I appealed.
No luck.
I will have to pay out of pocket, which kind of defeats the idea of being in a MA plan to begin with.
When I was on the phone talking to a representative of Aetna explaining that the drug was not being prescribed for erectile dysfunction (regular Medicare won’t cover it for erectile dysfunction either), I caught myself.
“Wait,” I said. “Even if I needed it for erectile dysfunction, why has Aetna decided that as someone over 65 I can only fuck six times a month?”
Only I didn’t say fuck.
Aetna’s service representative chuckled and then said, “I have no idea.”