I have employer provided health coverage in GA. My PBM is Express Scripts, and my medical insurance is through Aetna. I have a $4k deductible and $10k OOP max which are shared across medical and pharmacy. After the $4k deductible, co-pays kick in for pharmacy and co-insurance for medical. I take some expensive medication, and I usually hit my $4k deductible on my first medication fill of the year.
There is some delay in the electronic communication between Express Scripts and Aetna about spending. I think maybe it only gets updated once a month. This has never been an issue, but this year, I also had a medical procedure right at the start of the year. So basically the the timeline is:
1/5 – I have a medical procedure. Nothing is paid or billed at time of the procedure.
1/8 – I fill a prescription and pay $4k OOP for the medication.
1/22 – I finally get the bills for the 1/5 procedure (~$1500), but since Aetna hasn’t received any info from Express Scripts yet on my spending, I am billed as if I have not spent any money so far this year.
How is all of this supposed to play out? My assumption is that it’s based on actual service date. Therefore I need to pay the bill for the 1/5 procedure, and then when everything gets trued up that I would get a refund check from Express Scripts?
submitted by /u/Exacta7
[link] [comments]
I have employer provided health coverage in GA. My PBM is Express Scripts, and my medical insurance is through Aetna. I have a $4k deductible and $10k OOP max which are shared across medical and pharmacy. After the $4k deductible, co-pays kick in for pharmacy and co-insurance for medical. I take some expensive medication, and I usually hit my $4k deductible on my first medication fill of the year. There is some delay in the electronic communication between Express Scripts and Aetna about spending. I think maybe it only gets updated once a month. This has never been an issue, but this year, I also had a medical procedure right at the start of the year. So basically the the timeline is: 1/5 – I have a medical procedure. Nothing is paid or billed at time of the procedure. 1/8 – I fill a prescription and pay $4k OOP for the medication. 1/22 – I finally get the bills for the 1/5 procedure (~$1500), but since Aetna hasn’t received any info from Express Scripts yet on my spending, I am billed as if I have not spent any money so far this year. How is all of this supposed to play out? My assumption is that it’s based on actual service date. Therefore I need to pay the bill for the 1/5 procedure, and then when everything gets trued up that I would get a refund check from Express Scripts?
submitted by /u/Exacta7 [link] [comments]Read Morer/HealthInsurance