Ostomy Supplies & Prescription

[Jenbritish]

Hi,

I just ordered a different flange/skin barrier because 1) my stoma changed slightly and 2) I was getting leakage so wanted to try a different type. When I put the online order into Edgepark, I first had to update my insurance. Okay - no problem - I understand they need to verify coverage but then they tell me they need a new prescription from my dr because I'm getting a different flange. What the heck??? My condition hasn't changed so why do they need a prescription? I find this stuff stupid and annoying!!! I can see if I had a new condition and was buying whole new type of medical supplies but these are the same type of supplies - just a different size/style.

Let me know if you've run into this also. Thank for letting me vent and also hear from others who've had the same type of issues.

[Mara]

I don't know what type of insurance you have but it is the same with the original Medicare that I have. I agree with you 100% but that seems to be the way the rules and regs were written....

[ron in mich.]

Hi Jen yes i,ve had that same problem with BCBS and what really bugged me was my local supplier had ran out of my product so i asked to substitute and they said cant do that without new script and okay from ins.. So i called another local supplier that took care of that for me and i,ve been with them since without any problems.

[NEskier]

I am always 'amused' (take that word any way you like) to need a prescription, especially annually, for a product we need to live. What would we do with them otherwise?! Unless they think we'd sell them on the ostomy black market or something!

[BillGK]

This may not be an insurance issue, depending on how your prescription is written. My prescription is written pretty generically, so there is a lot of latitude in the supplies that can be provided under the prescription. However, if your script is written with specifics it may be that you need a new script.

[Mara]

@NEskier - well, have you ever noticed all the ostomy supplies on Ebay? Possibly some folks have more supplies than they can use and do sell them. I wonder if their insurance company paid for them....

@BillGK - the company that I order from faxes a prescription to my doctor for his signature - so I am thinking it might be specific....Since my doctor has no idea of what ostomy supplies I use I really don't feel I should ask him to write up an Rx....

[steiconi]

My supplier talks directly to my doc about prescriptions. Has anybody else noticed that most docs seem to be a little bit afraid of anything to do with ostomies?

One supplier chided me for changing my order because it would be inconvenient for my doctor. Um, I don't make these stupid rules, go lecture Medicare.

[NEskier]

@Mara - good point about eBay. I'd rather wondered at one point when I was hunting for something that had fallen off the supply chain after the hurricane hit PR.

My doctor was not asked for an annual scrip for supplies until I started on Medicare. The supplier started asking for this on the annual date of my Plan 65/Medicare start date. So I'm guessing it's Medicare. @steiconi - my PCD figures I know more than he does and just OKs what he sees!

[Mysticobra]

I've only been on Medicare a year and a half.
My observation dealing with them so far.
They just make older people jump through more hoops than necessary.
Whether it is ostomy supplies. Or prescriptions. Or Dr visits.
I had great insurance through work for 30 plus years.
I guess I was spoiled.
On top of everything Medicare is more expensive. Which is great for us on limited incomes.
Richard

[sabresfan18]

Just curious: is the pharmacy Edgepark?

[Mara]

Richard - I have had the opposite experience with Medicare - other than having to obtain a Rx for ostomy supplies, I have had no other problems. All my medical visits are paid for with no issues at all and my supplementary pays the rest. I have original Medicare not an advantage plan....

[Mysticobra]

Medicare has covered most.
But I had an emergency and was in the hospital 2 plus days.
Being on limited income. And the results of my hospital stay. (no answer)
I still had to lay out of pocket way more than I can afford.
I have c&d supplement. I'm afraid to use it. As I may incur more out of pocket I can't afford.
I need to go to a dentist. And optometrist.
As for ostomy supplies I have enough in my closet to last 5 years. Lol.
All my ostomy supplies are covered. Thank goodness for that.
I'm new to it. Just confusing. That's all.
Richard.

[steiconi]

It's probably going to get worse, there will now be a company trying to reduce the benefits you get from Medicare, called a DCE, and working kind of like an advantage plan, but you don't get to choose them.
If you have traditional Medicare, you'll be assigned to a DCE, usually based on your doctor's affiliations.
This company will review all your Medicare billings and can reject any they think shouldn't be covered. That might include ostomy supplies, or if a doctor orders a test you've had recently. I suspect we'll be getting charged for overages.

I've already gotten a letter from my new DCE.

Summary from one place:
This year your Traditional Medicare will not be direct point contact between you and Medicare. Your care is being turned over to private insurance co's that are called Direct Contract Entities (DCE's). They will now be the middleman between you and Medicare. They will decide what care you can receive and what care you cannot, and if privatized insurance is any indication they will be rejecting more requests for care than they approve. Why? Because the money paid to them to manage your care that doesn't get spent on your care they get to keep!

More:
https://pnhp.org/news/direct-contractin ... -medicare/

[Mara]

https://innovation.cms.gov/innovation-models/gpdc-model

It looks like your doctor has to be a provider who accepts this type of plan....hopefully none of my docs will.....
Thanks for the info, Lee!

Richard, I don't understand why you don't use your supplemental insurance. I had heart surgery last October. The complete bill came to well over six figures - all I had to pay was my hospitalization deductible of $300.....

[Jenbritish]

Yes - I’m using Edgepark. Right now I’m with BCBS but my company was sold and the new insurance has all kinds of co-pays and coinsurance (still BCBS). Worried about how much more out of pocket I’m going to have now. 4 years away from retirement age but figured I won’t be retiring for quite awhile