TRS-Aetna Disputed Drug Claim

By Edwin S and Marion D Herndon

This is the story of our dispute with Teachers Retirement System(TRS) of Texas over the Denial of Prescription Drug benefits.
In Februrary 2007 Aetna, as agent for TRS, denied prescription medicine charges because we had purchased the drugs in Canada.
They were delivered to our door by the United States Postal Service. The Drug manufacturers oppose the importation
of drugs from anyplace, Canada included. We save considerably by doing so. The Insurance companies like any excuse for not paying Claims.. We are the victims and we seek redress.

Our primary Insurance is Medicare parts A and B. The only Drug Coverage we have is through the TRS-Care Plan. The plan
is a "Major Medical" kind of plan that will pay 80 % of all covered costs over a deductible of $1800 per person, or $3600 for family.
It covers what we pay to Doctors and Hospitals after Medicare, Plus our out of pocket drug costs. The past plan year we paid about $2200 dollars to Doctors and Hospitals after Medicare. We paid roughly $2200 for drugs out of pocket. We expect TRS-Care to honor their obligation on these drug purchases and reimburse us in accordance with the plan documents.

The Evidence

The Material presented below was painstakenly extracted from the Aetna OnLine Navigator Web Page. These records are not in dispute by us, they support our claim. We no longer get Paper copies of our claim records. Aetna no longer writes to to tell you about the Non Approval of Claims. It is left to the Claimant to discover this at the End of the Plan year. Aetna does issue ocassional "your records have been changed" messages via Email. These messages do not point out the Change that has been made... You must do a Forensic Search to see what is new.

Report Card Clarity of Communication : F

Marions Not Approved Drug Charges:

These are copied from the Medical Claim Summary Table

06/16/06 to 06/16/06	MARION 04/06/36	Medical	Not Approved	489.88 Details	NO ASSOCIATED PROVIDER	$ 0.00	$ 489.88
02/06/06 to 02/06/06	MARION 04/06/36	Medical	Not Approved	282.81 Details	NO ASSOCIATED PROVIDER	$ 0.00	$ 282.81
02/06/06 to 02/06/06	MARION 04/06/36	Medical	Not Approved	267.81 Details	NO ASSOCIATED PROVIDER	$ 0.00	$ 267.81
11/15/05 to 07/11/06	MARION 04/06/36	Medical	Not Approved	763.23 Details	NO ASSOCIATED PROVIDER	$ 0.00 Total of above	$ 451.31 $ 1,491.81

You have to read an EOB to find the TRS/Aetna reason for Denial. The text is in a Footnote at the Bottom

Explanation of Benefits for Feb. 20, 2007 Claim

Edwins Not Approved Drug Charges

Unfortunately These are not properly labeled as "Not Approved" in the Claim Summary Table; they are listed as "Completed",
so one must search the Claim Details to Discover that these Charges were not applied to the Deductible!

Date of Service/Service Provided	Charges Submitted	Charges at Aetna's Agreed Pricing	Your Plan Paid	Not Paid	Your Deductible	Your Copay	Your Responsibility
11/15/2005 Prescription Drug	$109.76	$109.76	$0.00	$109.76	$0.00	$0.00	$0.00	Y
11/15/2005 Prescription Drug	$127.63	$127.63	$0.00	$127.63	$0.00	$0.00	$0.00	Y
Total	$237.39	$237.39	$0.00	$237.39	$0.00	$0.00	$0.00
				Your Responsibility: $237.39

Note: The Remark Y at the right of each of these Lines leads to a PopUp Window that says:

1. Due to federal law, Aetna does not cover drugs purchased outside the U.S. if such drug is intended for use in the U.S. The USFDA expressly forbids such purchases. If, however, this drug was purchased on an emergency or urgent basis while on business or vacation outside the U.S., or if the member was a resident of such country at the time of purchase, this information should be brought to our attention.

Close Window

Report Card: Hiding the Facts : A+ Timeliness of Posting : D

Date of Service/Service Provided	Charges Submitted	Charges at Aetna's Agreed Pricing	Your Plan Paid	Not Paid	Your Deductible	Your Copay	Your Responsibility
07/06/2006 Prescription Drug	$134.01	$134.01	$0.00	$134.01	$0.00	$0.00	$0.00	Y
07/06/2006 Prescription Drug	$130.25	$130.25	$0.00	$130.25	$0.00	$0.00	$0.00	Y
Total	$264.26	$264.26	$0.00	$264.26	$0.00	$0.00	$0.00
				Your Responsibility: $264.26

Date of Service/Service Provided	Charges Submitted	Charges at Aetna's Agreed Pricing	Your Plan Paid	Not Paid	Your Deductible	Your Copay	Your Responsibility
03/28/2006 Prescription Drug	$134.01	$134.01	$0.00	$134.01	$0.00	$0.00	$0.00	Y
03/28/2006 Prescription Drug	$130.25	$130.25	$0.00	$130.25	$0.00	$0.00	$0.00	Y
Total	$264.26	$264.26	$0.00	$264.26	$0.00	$0.00	$0.00
				Your Responsibility: $264.26

The Total of Edwins Non Credited charges is $ 765.91
The Total of Marions Non Credited charges is $ 1,491.81
The Family Total is $ 2,257.72

Plan year 2005 Deductible is Met

The EOB dated 11/04/2006 shows that for the Plan year 09/01/2005 to 08/31/2006 that there
there were $ 2,263.37 in approved Medical costs, There was a was a remainder of $1,336.73
to meet the $3600 deductible. Our Drug costs were greater than this amount so we filed a claim.

Click here EOB for 11/04/2006

TRS Should have the following Reckoning:
The Approved Medical Costs      $ 2,263.37
Drug Costs Not Approved above      $ 2,257.72
                            Total Bills      $ 4,521.09
                    Less deductible   - $ 3,600.00
                      Covered By plan    $ 921.09 Paid at 80% = $ 736.87

At this point we request that TRS-Care settle for $ 736.87

Should we go to Court I will sue for the full $ 2,257.72 Plus costs, because that is what TRS-Aetna disapproved. How much we have in Approved Costs does not mitigate the damage done!

Hypothetical Outcome

Incidentally we repriced all of the Drugs using CVS prices. The Price was a staggering $ 5,842.71

See Microsoft Works Spreadsheet Drug Cost Comparison

Our Frugal Buying Saved Us   $ 5,842.71 - $ 2,257.72 = $ 3,584.99

Suppose we had Purchased the Drugs at CVS and Filed the Claim,
TRS Plan would have the following Reckoning:
The Approved Medical Costs    $ 2,263.37
Drug Costs estimated above      $ 5,842.71
                            Total Bills    $ 8,106.08
                     Less deductible   - $ 3,600.00
                    Covered By plan    $ 4,506.08 Paid at 80% = $ 3,604.86

Our Frugal Purchasing Saved TRS $ 3,604.86 - $ 736.87 = $ 2,867.99

We should be getting a Medal Instead of a Denial of Benefits.
Aetna is being a bit Piggy Saving all of the Bananas.

TRS Care: Your Group Plan Booklet

The TRS Care plan booklet is included as a PDF document on this web page . See Your Group Plan Booklet 2006
This is the year 2006 Plan Booklet... The 2005 booklet was essentially the same. It was not available to me in PDF.
This Document governs the Plan.. We signed Up for It with TRS..... Aetna Should Administer According to the Plan.

Note: Marion and Edwin are members of TRS-Care Group 1. Our Primary coverage is Medicare Part A and Part B
We are not participants in the Caremark Prescription plan offered to TRS - Care Group 2 and 3 Members.
We rely on TRS-Care 1 to be our protection against Catastrophic Losses.

The following Notes cite page references to the document. They establish the Basis for my claim.

Page 7-8 Table of Benefits This table establishes $3600 as the Family Deductible for TRS Care 1
It also acknowledges that Drugs are Covered Charges and that after the deductible is met, Benefits are paid at 80 %

Page 37 has a Green box

Filing a claim for Reimbursement (TRS- Care 1 Participants ) To receive a reimbursement of covered prescription drug expenses, plan participants covered under TRS-Care 1 need to file a paper claim with Aetna. After completing the prescription drug claim form, submit it with your original prescription receipt(s) to Aetna.

Please note that I filed a paper claim in October 2006 and It was never acknowledged...
When I called in November , the agent said, "It must have been Lost in the Mail".

We suspect that the paperwork may have been conveniently discarded or lost by Data Entry.
The first easy step in denial of a claim is to say "we never got it." At that point the claimant may give up.

During November and December I spent several days obtaining Copies of all statements previously lost by Aetna
These were FAXed On Jan 9 to Aetna but somehow were never entered into the system..
They were FAXed again on Jan 24 and some of the material was entered into the system.
The missing piece was never found so I FAXed it again.. That was on Feb.5 2007.
This last piece was entered on Feb 20, 2007.

Report Card on Data Entry D (It should not take 2 weeks to enter a simple claim... Materials Should Not be lost! )

What are Covered Drugs?

Page 39 has an Exhausting list of Exclusions:

Exclusions (TRS-Care 1, TRS-Care 2, TRS-Care 3)

Items not covered by the prescription benefit program

Any medicine that is not medically necessary
Any experimental or investigational medicines
Any fertility medicine
Any medicine wholly consumed at the time and place it is prescribed
The administration or injection of any medicine
Any prescription refilled in excess of the number of refills specified by the doctor and/or any refilldispensed after one year from the doctor's original order
And the List goes on
and on, 22 bullets total, including:
Non-federal legend medicines
Smoking Deterrents (over the counter)
Theraputic devices or appliances
Any medicine that is not approved by the Food and Drug Administration.
There are more; you can read them in the booklet

Presumably Covered Drugs are any Drugs Not Excluded Above.

Notably the drugs which we claimed: Lipitor, Norvasc, Premarin, and Nexium, are all FDA approved Drugs.
They are Not Excluded from Coverage by the plan.

If ever there was a place to warn that Drugs procured outside the United States are Not Covered, This Table Is the Place.

Instead the ONLY Written Prohibition from TRS or Aetna is contained in a Footnote to a detail item on the Web page.
It is Hard to Find... It is not in the Book for 2005 nor 2006!

Failure to Truthfully and Accurately spell out exclusions is Negligence on the part of the Plan administrator.
This Negligence and Misinformation is the Crux of this claim.

Report Card: Truthfulness F

Drugs from Outside the US covered

Page 58 in the 2005 Booklet-- Frequently Asked Questions Section
(a similar statement appears in the 2006 booklet but This claim is for 2005)
I quote:

Q. If I obtain a prescription outside the United States, can I file a claim?

A. Mail a copy of your prescription and purchase receipts along with the Caremark Prescription Drug Claim Form. The Mailing Address is on the Back of the Form.

For the 2004 Plan year we filed a claim for Drugs Purchased in Canada.
They were applied to Marion's deductible and we got a small refund.

In time for the 2005 plan year, Edwin was added as Spouse to Marion's Plan.
During the 2005 plan year we purchased our drugs and collected our receipts anticipating
that we may need to file a claim.

Obviously there was no reason not to continue purchasing in Canada... We saved money doing so.
The Plan Booklet said FDA Approved Drugs are covered.

How Did We find out that our claims were Not Approved?

Aetna never notified us, we had to call and discover what was happening!
Not Once But about a dozen times!

Report Card Responsive Communications F

Total Surprise: Frank Di Lorenzo, TRS guy in charge, called to inquire about my concern...
After five months he was the Only one to ever call..
I must admit I was Harsh on the phone... He was very patient; I bordered on Abusive..
Please accept my appologies...

Dear Frank, Fire Aetna as administrator of the plan...
They are Incompetent! Just read the report cards...

Action List: things to consider doing

Recontact Frank Di Lorenza TRS show him this page
Contact our lawyer for some free consultation
Forward this complaint to the Aetna Appeals process
If we are denied, Publish this web page on the Internet.
My Brother "Ace Retired Journalist" from LA times needs to hear this one!
Write Congressman Nick Lampson (my district), He is sympathetic to Seniors.
You Know Aetna did not create that footnote just for us...
There must be thousands of TRS Care participants getting the same treatment...
Maybe Organizing a Class Action Suit is the Right Thing to do.
Contact Frank Kaiser suddenly senior. He would love this story! Go get copy of the article

US TO STOP SEIZING
CANADIAN MEDICINE

BY JOHN CARREYROU, Wall St. Journal
OCTOBER 4, 2006

Under pressure from Congress, U.S. Customs and Border Protection officials scrapped their 11-month-old policy of seizing prescription drugs imported through the mail from Canada.

Pleasant Dreams....

Free Counter