Health Insurance copay question

Insurance Forum Health Insurance
1

My oncology medication is a non-preferred Tier 4 drug on my insurance plan. I confirmed with my insurance company today that my copay for it should be $200. But the oncology pharmacy has been charging $2,000 a month to my pharmaceutical company copay card. Here’s more detail and my question:

I met my deductible early this year, and I’ve been taking this Tier 4 medication since 2017, so it’s not a new prescription. I’ve been using a copay card to help cover the cost, but this year it’s been running out of funds much sooner than expected.

After seeing in my new enrollment paperwork that the copay should still be $200, I called my insurance, and they confirmed that amount. But the pharmacy is charging $2,000 to the copay card each month. I notified my insurance company last month, and they said they’d look into it, as I need to know the correct copay for next year when my deductible resets. I called again today, but they haven’t gotten back to me.

Any ideas on why they’re overcharging the copay card? The copay card was meant to help cover costs throughout the year, so I was surprised to run out of funds so early.

Thanks for any thoughts on this!

2

What type of insurance do you have, and how did you get it?

Is the pharmacy in-network?

Is the pharmacy sending claims through your pharmacy or medical benefits?

Does the medication require prior authorization, and if so, did the pharmacy or your doctor handle it?

What do your EOBs (Explanation of Benefits) show as your copay?

3

@Vero

4

@Mai

5

@Mai
It sounds like the pharmacy might be billing the copay card as primary by mistake.

Is this medication something you take at home, or do you receive it at your doctor’s office?

Also, it’s possible your insurance requires them to bill the copay card first, then insurance. Since you get this through your union, see if they have a plan broker who can help, and reach out to the pharmacy too.

And you might want to post over at r/HealthInsurance—there are folks there who work with specialty pharmacies and health insurance who might have a better idea of what’s going on.

Glad the medication is working for you!

6

@Vero
Thanks, I’ll post there!

Yes, this medication is a pill I take at home. I do get other meds at the cancer center, but those are billed on the medical side since they’re considered chemotherapy.

I also see my oncologist monthly for labs, exams, and the medication I get there. The union connected me with a patient advocate who put me in touch with someone at the insurance company, but I haven’t heard back yet. Appreciate your response!