I have an employer-sponsored health insurance plan that is composed of separate medical and pharmacy plans (with separate deductibles / OOPM’s). I believe my employer is self-insured. According to my summary of benefits, my pharmacy plan (administered by Express Scripts) is supposed to have a $1,500 OOPM.
However, it came to my attention recently, after reviewing my pharmacy claims history on the Express Scripts website, that I have paid $2,300 out-of-pocket during this benefit year (i.e. $800 over my OOPM). Despite this, Express Scripts continues to charge me co-pays for my prescriptions.
I called Express Scripts and spoke to a supervisor, and she could not figure out why I am still being charged co-pays. She also said that the plan details of my particular plan were very vague regarding the specific nature of my OOPM. Basically she said that, whereas other plans will typically specify the coinsurance percentage that will be charged after reaching the OOPM (typically 0%), my plan only says that co-pays/coinsurance will be “reduced” . That’s supposedly all it says. I then called my company benefits hotline, and they also had no explanation for this.
The supervisor at Express Scripts filed some kind of claim for reimbursement and said that I should expect to hear back within 10 business days. But honestly, short of suing them in small claims court or something, I’m a bit stumped as to what to do next if the claim gets denied. With literally every other health insurance plan I’ve ever had, “out-of-pocket maximum” literally meant “the plan pays 100% of covered costs after you reach the OOPM”. So this is just very confusing to me.
Does anyone have any thoughts as to what the deal might be here, or what questions I should be asking?
submitted by /u/Xiaolingtong
[link] [comments]I have an employer-sponsored health insurance plan that is composed of separate medical and pharmacy plans (with separate deductibles / OOPM’s). I believe my employer is self-insured. According to my summary of benefits, my pharmacy plan (administered by Express Scripts) is supposed to have a $1,500 OOPM. However, it came to my attention recently, after reviewing my pharmacy claims history on the Express Scripts website, that I have paid $2,300 out-of-pocket during this benefit year (i.e. $800 over my OOPM). Despite this, Express Scripts continues to charge me co-pays for my prescriptions. I called Express Scripts and spoke to a supervisor, and she could not figure out why I am still being charged co-pays. She also said that the plan details of my particular plan were very vague regarding the specific nature of my OOPM. Basically she said that, whereas other plans will typically specify the coinsurance percentage that will be charged after reaching the OOPM (typically 0%), my plan only says that co-pays/coinsurance will be “reduced” . That’s supposedly all it says. I then called my company benefits hotline, and they also had no explanation for this. The supervisor at Express Scripts filed some kind of claim for reimbursement and said that I should expect to hear back within 10 business days. But honestly, short of suing them in small claims court or something, I’m a bit stumped as to what to do next if the claim gets denied. With literally every other health insurance plan I’ve ever had, “out-of-pocket maximum” literally meant “the plan pays 100% of covered costs after you reach the OOPM”. So this is just very confusing to me. Does anyone have any thoughts as to what the deal might be here, or what questions I should be asking? submitted by /u/Xiaolingtong [link] [comments]Read Morer/HealthInsurance