Surprise! Surprise! The Answers Aren’t Always There!

I get to join the rest of the people who are adjusting to new insurance plans this year.   My company changed coverages, albeit the changes are somewhat slight.  Some are actual improvements, some are definite changes.  Most straightforward but a few that should be simple are anything but that.

I’m having a heck of a time trying to figure out my prescriptions. The prices & classifications (tiers) are not the issue. It’s where I can get them from & how many pills at a time.  It doesn’t really say, for sure, in a clear manner.

It looks like specialty has to be filled by Aetna Home Delivery or a retail pharmacy versus Caremark mail order or their specialty pharmacy, but the rest of the prescriptions can be filled by my local CVS, I think…

The rub is where the regular, non-specialty 90 day refills fall into the mix. Do I have to fill them through Caremark mail order or can I get them at a local CVS? Or do I have to use Caremark instead of Aetna Home Delivery for regular mail order refills?

Or does any of this even really matter at all? Can I just get everything at my local CVS as I need it?

I was previously registered for Caremark last year but it’s not recognizing my old login info, nor is it allowing me to set up a new account. It’s just throwing errors on whatever I try to do with a vague network error issue, but keeps saying my credentials are invalid.

I can’t do any of this work with sorting this mess out right now.  But it’s a headache I’m not set to tackle tonight.  I’ll save it for next week or see what my local CVS can do first, hopefully they can save me a phone call.

It really shouldn’t be that hard to make this information clear to people.  But the language in the plan information is ambiguous & it doesn’t outline it correctly for me to find the answer myself.

Overall, it doesn’t look like there too many benefit changes from last year at first glance.

I still have a few specific questions. I’m having issues locating information for things other than just my pharmacy benefits, too.  It’s also unraveling a few nuances of how my benefits are covered that has me confused.

I’m missing how straightforward the layout was on the old plan on searching for benefits. This new book (even though it is complete) is not as user-friendly so I can’t locate the answers myself (even though I tried).

Some of it is mission critical to me since it’s not spelled out.  I’m not sure whether I do or don’t have the benefit anymore or how much it changed.  I find that concerning.

[Prime example: Do I still have a lodging/housing benefit after transplant & if I do, is there a dollar or day restriction & how do I go about submitting that information for reimbursement? This was all something that was laid out in a special section in specific detail under my old plan in several places.   In the new plan I found a one-line reference that says it may not be covered if it is out-of-network but gives me NO information of how it is covered in-network.  Last year’s plan had a dollar amount maximum just for this benefit alone.  Specific detail was laid out as to what types of expenses were eligible to be reimbursed & how to claim them. See the difference?]

This was the kind of thing that would drive me crazy as a CSR when I would help people compare & contrast plan changes from their old plan to a new plan that the company I worked for created & administered (for their employer) when they called up & had many of the same questions I’m asking now.

I often wondered how people made sense of the way some of this information was organized because it took me about 20 keyword searches to find the info for them in their old booklet. Then another 10 minutes to outline the difference in the plans & verbiage once I reconciled the two. I felt their pain, believe me.)

I was right when I bitch about insurance companies making this kind of information glaringly obtuse & ambiguous. Now, I’m the one with the issue on the personal end & my professional skills can’t solve it right now.

I’ve used every old trick I remembered try to locate the information myself, with no success.

This means on Monday or Tuesday (whenever I can call) which are usually the highest call volume days for most insurance companies,  I’ll have to try & get an answer (probably after at least a 15-20 minute hold time at minimum).

It will probably be fruitless because the agent will be looking at the same info I have & scratching their head the same way. They will then tell me I have to wait 48 hours for a clarification while they escalate it.

Oh, well. Join the club.

But as usual, (even if it takes a moment)  I’ll find a way to deal with it.

Maybe I need to do a search for decoder rings on Ebay…

UPDATE 1/11: So I woke up early & got through in a decent time frame. I only held when she checked on the benefit I couldn’t find.  They are saying my lodging/housing is covered as long as the center coordinates it & it is a facility of excellence (which it is).  I’m still somewhat skeptical but I guess I’ll find out.   I also got the precertification & prior authorization numbers for both my transplant services & any drugs that need authorization.   My CVS can only fill 30 days at a time, mail order goes through Aetna Home Delivery which I figured (but then why was it allowing me to run tests in Caremark’s system?)  Thus the move my company made from them being self-funded to fully insured this year is the reason for the ambiguity which I figured.  Self-funded plans are laid out so much better & easier to follow.)

UPDATE 1/12: After updating my team to ask that they precert everything ahead of my next check in, I received a call from the Aetna authorization team & a case manager.  It turns out, that they approved everything, but that I don’t live within the “radius” to qualify for the housing benefit.  Yet another reason I was glad my fundraising efforts were successful. It won’t be a horrific expense, but I sensed that I might not have that benefit for long last year & it turns out I don’t.  Another casualty of change… Luckily, the houses are reasonable & I have enough socked away to not have to worry about it because I planned ahead for unanticipated expenses, too.


2 thoughts on “Surprise! Surprise! The Answers Aren’t Always There!

  1. SMH Nikki about your situation and understandable frustration. Takes me back to our conversation on the topic.

    It’s a truly sad commentary that our health insurance has become so complex. When individuals, like you, who worked in the industry, can’t decipher their benefits, what chance do the rest of us stand?

    Your post finishes with your trademark optimism and determination. I’d strongly recommend you prepare a trusted family member or friend with key learnings once you’ve successfully navigated the murky waters.

    Knocking Wood for U!

    Liked by 1 person

  2. I had Aetna from 2009 to 2015. In the last two years of the plan, I was having a crazy hard time trying to navigate the medications and unusual but necessary portions of my care too. For instance, no one in the customer service area could tell me if the silicone allergy specialist I needed to see in the Mayo Clinic’s Phoenix office would be covered and considered in-network or out-of-network; it all depended on how the bill was prepared, like would it say “Mayo Clinic” or the physicians group that particular doctor belonged to? So I had to wait until it was hashed out in the business office to find out which part of the negotiated price, which was over $6k, I would be responsible for.

    CVS…well, that’s another long and drawn-out story.

    Obviously Aetna is struggling with complying with regulations while still trying to profit from our bodies.

    Liked by 1 person

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