HMO.

I've had my health insurance provided via HMO before, and - unlike many other people I've talked to - I've generally had good experiences in the past. Rather than dealing with a byzantine set of hassles and irritations that seem designed to thwart, rather than encourage, health care services and products being provided to the subscriber, I've typically found that things were actually pretty smooth and easy.

Sadly, I've encountered increasing hassles lately with my HMO: cancelled appointments because authorizations weren't provided in time, obviously unneccesary appointments required only because Dr. X had to sign off on what Dr. Z had recommended, etc. Mostly minor stuff, but definitely irritating.

Today, I dealt with another irritation that, though minor, bothers me to no end. Rather than explain it, I'll just reconstruct the conversation between myself and the customer care specialist I called at my HMO. Her replies are in italics:

(Assume 5 minutes of frustrating phone tree prompts and automated responses that precede this.)

"Thank you for calling (name of company), my name is (whatever), how can I help you."

"Hi, my name is Kevlar Pinata (not my real name, by the way), and I have a question about my prescription coverage."

"Okay Mr. Pinata, can you give me your membership number?"

"Uh, sure, but I just gave that to your automated system five minutes ago. That information doesn't appear on your screen?"

"No sir."

"Oh, okay. Here it is. (I give my number.)"

"Can I have your date of birth?"

"Yeah, but I did already give this to your system."

"Yes sir, I understand. But I don't have it."

"Okay. (I give my date of birth.)"

"Zip code and daytime phone number?"

I sigh and then I give it.

"Okay, how can I help you?"

"I have a prescription that used to have a thirty-five dollar copay, and I went to pick it up and they told me my copy was fifty dollars. Can you shed some light on that for me?"

"Certainly. Give me a moment."

Pause.

"Okay, I see here that your prescription has been changed from being a brand name medication to a specialty medication and the copay increases from $35 to $50 in that case."

"But my prescription didn't change. I'm taking the same medication - it was just a refill."

"Yes, I see that. However, the drug changed from brand name to specialty."

"No, the drug didn't change. Your classification of the drug changed."

"Well, what happens is that a drug is either generic, brand name, or specialty, and they each have a different copay. Your drug was brand name but now is specialty. So obviously, it changed."

"No, it didn't. Pharmaceutical companies spend millions of dollars developing drugs and it takes years to get FDA approval. They don't just change the formulation of what chemicals are in a drug on a whim. The drug is the same today as it was yesterday and the same as it was last year. The drug has not changed."

"Yes sir, that's probably true. But it's a specialty drug now."

"So what you're saying is that your classificaiton of the drug changed. The drug didn't change - it's just that some person or some committee in your company decided to reclassify it as 'specialty' instead of 'brand name'. Did anyone think to contact me about this?"

"Well sir, I'm sure that we would have sent a letter."

"It's certainly possible that I received the letter and misplaced it, but I don't remember getting a letter."

"I'm sure we sent a letter.

"Okay, well, I understand that this isn't your fault, but please understand that my employer and I don't pay you any less for health care coverage than we used to. And understand that my prescription hasn't changed - either with regard to the medicine that is prescribed or the amount I take. And in spite of all of that, I now need to pay more for the exact same drug that I've been taking all along. Does that seem reasonable to you?"

"Sir, I can give you a list of alternate drugs you can suggest to your physician that would be less expensive with regard to your copay."

"Fine. Can you give me that list?"

And then I get a list of drugs (at least one of which is over the counter and therefore will not require my HMO to pay anything) that I have to call my doctor with to see if any of them will work. To a degree, I like to have input and choice with healthcare, but I guess I have an old-fashioned notion that the doctor ought to know what the best drug is, and that I shouldn't have to call his office and say "well, how about something different?" He is, after all, the doctor.

So, I have to comparison shop my medications now. Which is okay, I guess. I just don't like the rules of the game changing on me.