Calling Aetna

Aetna sold me a pharmacy benefit that read "$2,500 maximum annual out-of-pocket expense," then switched it to read "$2,500 maximum annual benefit" once my policy started.

I've been fighting it, but to no avail. I understand how the mistake happened - they were selling me the policy in December, then changed it with the new year without warning or notice.

So since my monthly drug costs are around, hmmmmmmm, $6,000 a month, I can reach their $2,500 maximum benefit really fast.

The chemo drug Nexavar, by far, costs the most, clocking in at just under $5,000. But an appetite stimulant goes for $500 a month, another for just over $100, and another the same, and on and on.

So far Bayer Pharmaceuticals has been generous enough to provide the chemo to me under a Patient Assistance Program. That status will be re-evaluated towards the end of this month.

The other costs Aetna will cover until $2,500 is reached and then I'm on my own.

Last year the benefits just ran out. I had no knowledge, no idea, just woke up one day, got a phone call and suddenly a month's supply of something cost me $200. I honestly never had any idea just how expensive prescription drugs have become.

This year I need to budget, question everything, keep track of all costs, to ensure I'm getting the most bang for the buck on every single prescription.

I've already decided that the $500 appetite aid is out. It certainly helped my appetite but at $500 a month I'd be out of pharmacy benefits for the year by May.

So the doc gave me some samples of something called Nexium. It is supposed to help calm my overactive stomach down, and I did think that it was helpful for the week I took it.

So yesterday I needed to call Aetna to find out more about Nexium, specifically what the real cost was so I could budget and plan, and decide whether this drug would break the bank or if I could afford it.

I dread calling Aetna. Most of the time, I swear, I think I'd be better off just dialing a wrong number.

Well first you must go through the questions and answers that the computerized woman's voice asks. She never seems to understand me so I end up shouting the answers back into the phone.

After meandering through the lengthy Q&A I am put on a hold for about 5 minutes. Suddenly a customer service representative answers the phone. The first thing she asks for is all of the same answers I shouted into the phone to the computerized woman.

"OK. What can I do for you Mr. Albert?" she asks.

Now I've been on the phone for about 10 minutes at this point.

I explain my situation to her, the $2,500 maximum benefit, how I need to find out true costs of drugs just not co-pay costs.

She's completely confused. She pulls up my policy and sees the $2,500 maximum pharmacy benefit. The benefit is so ridiculously poor and useless she refuses to believe that it works the way I explain to her. She rationalizes that I'm wrong and I should only be adding up co-pays to track when I'm reaching $2,500.

No, I explain to her, I've been through this. Yes, it is an unbelievably poor benefit but it's true. It's the true cost of the drug, and that's what I need to find out.

We pleaded with each other, begging the other to believe our stories. There was no doubt I had it right. Here I was explaining to an Aetna employee how my policy works.

She became exasperated with me and finally said that they have a seperate pharmacy division and maybe there was something she was missing and perhaps she should transfer me to the pharmacy side.

(SIGH) OK.

After another five minutes on hold I landed in the pharmacy division. I had to restate all the answers I had initially shouted into the phone to the computerized woman's voice earlier.

"OK Mr. Albert, how can I help you?"

I explained the whole situation again. My doc is wanting to prescribe a drug called Nexium and I need to find out it's true cost.

Again the csr began to tell me that I don't understand and I really do not need that information. She explained to me that "$2,500 maximum annual benefit" meant that I had to cover the first $2,500 before Aetna would cover anything.

"It's not a deductible. I have a $100 deductible, paid that on the first prescription of January. It's a maximum benefit," I explained, increasingly frustrated.

This was the second Aetna representative who did not understand Aetna's policies. This is not rare. This happens everytime I call.

Frustrated with me the csr asks if I can hold while she does some research. I've been here before too. I can sit on hold for 10 to 15-minutes at this point. Often times the line suddenly goes dead. Someone hanging up on me?

But this time I hang up, right away as soon as I'm put on hold. The lesson learned is if you get someone who has no clue what they're talking about, just hang-up and keep calling back. Sooner or later you'll get someone who knows something.

And that's what I do. I shout into the phone at the computerized woman's voice again. I sit on hold for another five minutes. And finally someone picks up and she knows exactly what I'm talking about, and understands exactly what information I need and why I need it.

Unfortunately, she explains, since we have different divisions I don't have any access to the total drug costs.

"How does my pharmacist always know what the costs are and Aetna doesn't?" I ask. "If you were in my position what would you do?"

"I'd call your pharmacist," she replies meekly.

I called the pharmacist. I was not on hold at all, one transfer and right to the pharmacist. I explained the situation. She understood completely. And she had the monthly cost of Nexium for me in less than 30-seconds - $125 a month.

"But there is an over-the-counter alternative," she said, "it's exactly the same thing and only will cost you $20 a month."

Why do I call Aetna?