I’m having trouble with my health insurance. I work for a local government and they have a plan made through a broker for us. I’ve worked here several years and the benefits have mostly stayed the same. This year they changed our medication coverage slightly and I now have to go through a specific pharmacy covered by our insurance. I take a speciality medication and there is a secondary specialty pharmacy that I am required to use. So the change in pharmacy and the new year, and my prescription ran out of refills all at the same time. So I planned ahead and got an appointment and a new prescription, new prior authorization, new labs, all the things, a month before I needed my next dose. It took 3 months to get a dose. It’s been a nightmare with everything.
The biggest issue I am having is that what my employee benefits packet says my coverage is and what the pharmacy says my coverage is, is different. The pharmacy says I have to pay 100% for brand name specialty medications and my benefits packet says insurance covers 85% with $150 max copay, and $100 deductible (per year). Also, $3,000 max out of pocket. The pharmacy is charging 100% to my copay card/patient assistance program, and has now exceeded the annual benefit. The patient assistance program said that the payments they’ve made should be applied to my max out of pocket, which isn’t happening. I’ve been complaining to HR about the whole mess, they’ve talked to the broker and pharmacy, and nothing is changing, since mid January.
In December, same medication, same dose, same benefits, different pharmacy, they would charge the copay card $145 and I would pay $5. Now they’re charging the copay card like $3,000. And the copay card is maxed out, so now they want me to pay cash over $6,000.
What do I do about the benefit/coverage from the pharmacy being different than what I signed up for and what I’m told should be covered? My medication is super important and I will become permanently disabled without it.
HR also forwarded my emails to the pharmacy/medication coverage branch after I explicitly asked them (in writing, in the same email chain) to get my consent before doing so. So I’m upset about that.
Any advice? Can they just not cover my meds, or rather cover them 0%?
Edit: Age 36, income $70ishk, Rural Colorado
submitted by /u/ghobbb
[link] [comments]I’m having trouble with my health insurance. I work for a local government and they have a plan made through a broker for us. I’ve worked here several years and the benefits have mostly stayed the same. This year they changed our medication coverage slightly and I now have to go through a specific pharmacy covered by our insurance. I take a speciality medication and there is a secondary specialty pharmacy that I am required to use. So the change in pharmacy and the new year, and my prescription ran out of refills all at the same time. So I planned ahead and got an appointment and a new prescription, new prior authorization, new labs, all the things, a month before I needed my next dose. It took 3 months to get a dose. It’s been a nightmare with everything. The biggest issue I am having is that what my employee benefits packet says my coverage is and what the pharmacy says my coverage is, is different. The pharmacy says I have to pay 100% for brand name specialty medications and my benefits packet says insurance covers 85% with $150 max copay, and $100 deductible (per year). Also, $3,000 max out of pocket. The pharmacy is charging 100% to my copay card/patient assistance program, and has now exceeded the annual benefit. The patient assistance program said that the payments they’ve made should be applied to my max out of pocket, which isn’t happening. I’ve been complaining to HR about the whole mess, they’ve talked to the broker and pharmacy, and nothing is changing, since mid January. In December, same medication, same dose, same benefits, different pharmacy, they would charge the copay card $145 and I would pay $5. Now they’re charging the copay card like $3,000. And the copay card is maxed out, so now they want me to pay cash over $6,000. What do I do about the benefit/coverage from the pharmacy being different than what I signed up for and what I’m told should be covered? My medication is super important and I will become permanently disabled without it. HR also forwarded my emails to the pharmacy/medication coverage branch after I explicitly asked them (in writing, in the same email chain) to get my consent before doing so. So I’m upset about that. Any advice? Can they just not cover my meds, or rather cover them 0%? Edit: Age 36, income $70ishk, Rural Colorado submitted by /u/ghobbb [link] [comments]Read Morer/HealthInsurance