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Max out of pocket medical vs. pharmacy
Old 08-26-2014, 10:20 AM   #1
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Max out of pocket medical vs. pharmacy

I've been receiving my copays returned from my PCP and other DRs for last 3 visits. Calling BCBS I'm at my max OOP for the year($2000).

But I'm still paying my copays for pharmacy benefits. Called Blue last week the first gal said there is only one max OOP, once you hit it your done for the year(assuming in network coverage and covered expense). She checked my medical and I've meet my max OOP. I can see that too.

When I talked with another Blue rep regarding pharmacy benefits she claims I'm $20 short of max OOP. I can't find what she's looking at(different system) Couple calls later she's escalated this to someone to research. First callback we rehashed that medical benefits says different totals than pharmacy benefits, she agrees they should be the same. Still waiting for next callback.

So my question is what have I missed? All DR. visits have been in plan for covered services. The same is true for pharmacy services. Anyone else had this happen? Thanks for any ideas.
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Old 08-26-2014, 11:42 AM   #2
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So my question is what have I missed? All DR. visits have been in plan for covered services. The same is true for pharmacy services. Anyone else had this happen? Thanks for any ideas.
I've noted a discrepancy between pharmacy and medical deductible/copay calculations with BCBS IL for this year, employerís group plan has a token HCA amount, which I think is throwing the pharmacy benefit calculations for a loop this year as they don't seem to be on the same page regarding plan benefit levels. I had contacted BCBS about it and they say they donít see any problems on their end. That being said, the benefit calculations are so obfuscated a process that Iím just waiting until all the deductibles and copays are showing on BCBS's statements, then reverse engineering how they arrived at those numbers.
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Old 08-28-2014, 04:07 PM   #3
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. That being said, the benefit calculations are so obfuscated a process that Iím just waiting until all the deductibles and copays are showing on BCBS's statements, then reverse engineering how they arrived at those numbers.
Thanks, I agree it's impossible to see the changes in max OOP on every bill. I got an update from BCBS. I wouldn't wait on them based on my experience.

Since I forced the issue they went back and determined my max OOP had accumulated to $2001.23. Their pharmacy system only checks for equal to the new accumulated OOP vs. the max(2001.23 is not equal 2000.00). So in my case they would never had quit charging for pharmacy benefits. Their fix was to set my accumulated OOP to exactly $2000.00. So going forward I'll have no copays.

The girl didn't like it at all when I told her 'BCBS has not honered my max OOP for prescriptions starting in March based on the EOBs, I want my money back. It's somewhere around $150.00 based on my calulations.'

She tryed playing the she can only see pharmacy benifits, not medical. While I appreciate her problems, they're not mine. Explained (nicely) I was the customer, really didn't care who at BCBS investgated or fixed it. She agreed to push back to their technical team as to how much I'm owed.

They also let it slip that some customers are experiencing this after they went to a 'new' system. I wouldn't wait for them to resolve it unless you push.
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Old 08-28-2014, 04:20 PM   #4
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It doesn't surprise me that the error benefitted the insurance company and damaged you. It also doesn't surprise me that there are uninformed reps answering the phones. It also wouldn't surprise me if it took you hours to get it fixed and they didn't offer an apology. I have come to dispise health insurance companies...they make me feel the least like a customer of any company I deal with.
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Old 08-28-2014, 09:27 PM   #5
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.....I have come to dispise health insurance companies..
And yet there are many, many folks subject to VA medicine who are begging for the chance to access those same HI companies rather than continue dealing with the repeated delays and substandard care they have had with the VA.

Cooper Says VA May Require Drastic Measures - NewsChannel5.com

Econometer: Replace VA with vouchers? | UTSanDiego.com

No system is perfect, but I would much rather fight a HI company which is subject to state insurance commission oversight (and potential civil litigation) than a faceless federal bureaucracy accountable to no one- even Congress (as recent events have shown ).
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Old 08-29-2014, 08:42 AM   #6
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BCBS customers, you are not alone. I had almost the exact same situation with Aetna. I just kept persistently calling and finally got it all resolved, including a reprocessing of claims which resulted in a refund.
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Old 08-29-2014, 02:48 PM   #7
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BCBS customers, you are not alone. I had almost the exact same situation with Aetna. I just kept persistently calling and finally got it all resolved, including a reprocessing of claims which resulted in a refund.
Congratulations on getting yours straight. I'm the OP, wasn't singling out bcbs. This stuff happens, as your suggest, with many HI companies. Many of these HI companies seperate out pharmacy benefits and have a 3rd party do that processing. Some parse out other parts of their business to other providers. Perhaps a better title would have been, "how do you know your copays and oop are correct?".

I am grateful I can go to the state insurance commision if need be. The HI company knows I can be a PIA, earlier in the year I formally protested a service and won. About 3:00 AM I woke up with an idea on how I might be able to reconcile all their data and prove exactly when their system broke. I'll try that tomorrow.

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Old 08-29-2014, 03:08 PM   #8
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No system is perfect, but I would much rather fight a HI company which is subject to state insurance commission oversight (and potential civil litigation) than a faceless federal bureaucracy accountable to no one- even Congress (as recent events have shown ).
Agreed. There are worse situations to be in other than having to deal with a HI company. It's just that they don't "get it" that I'm the customer and they are supposed to be serving ME. As it stands they say jump and I have to figure out exactly how to jump to their specification. If I don't stick the landing, my efforts are rejected or ignored.

With respect to state insurance commission oversight, that must vary state to state. My experience is that they might be more of a lap-dog than a watch dog. I'm expecting word back from NC DOI on a major complaint on which I've been getting stonewalled by BCBS NC. Luckily small claims goes up to $10,000! Even if I lose, at least they will have to spend a couple grand sending a lawyer.
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Old 08-29-2014, 06:05 PM   #9
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Aetna has no problem keeping track of my payments towards my premiums of $17,493.84 a year with them, but apparently it's too much to ask for them to keep accurate track of my deductibles and co-insurance payments. I give these guys no slack - their customer service absolutely stinks - with very rare exception, when I call in, nice as I can be, they make me feel like I'm bothering them - I've even asked before, "Am I bothering you?", "Uh, what do you mean sir?", "Well, you're treating me as if you can't wait to get me off the phone", "Oh no sir - we value your business". Yea, right.
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