Unexpected "credit" on Health Insurance

[PlayinwithFIRE]

This year, I switched family down to a Bronze Plan thru ACA to gain access to an HSA.

I have been using a biologic for about 2 years which has a hefty pricetag. Insurance doesnt "cover" a large part of
the price tag, so the biologic manufacturer provides a debit card to cover the rest of the cost. This essentially means
I pay $0 for the medicine.

Well, I just went thru a cycle of the biologic (once every 2 or 3 months) and noticed that my insurance registered an ~ $8800 contribution to my out of pocket max
for the year. Significant against a $21,000 family OOP max.

So I think I recieved credit for the biologic charge, even though the manufacturer actually paid for it. It means I
should hit the max in 2 or 3 cycles like this...which is somehwere about mid-year.

If this is all true, I look forward to 100% coverage in the second half of the year...I better start scheduling some major work

pwf

 

[PaunchyPirate]

So this is a quirk in the system that I discovered last year. It seems that the insurance companies cannot count manufacturers coupons/assistance in their numbers.

I use Mounjaro for my diabetes. They have a manufacturer's "coupon" (from Lilly) that can get applied to your costs so that you never pay more than $25 per month for it. This does not work if you're on Medicare, though. The coupon is not supposed to pay more than $150 per month, however, according to Lilly's terms. Also, the coupon has a maximum of $1,950 per year of assistance.

This year, I have a $1700 deductible with my HSA compliant insurance plan. So I would expect to pay nearly the full price of roughly $1000 for the first fill of Mounjaro. With Lilly perhaps kicking in $150. Then on the second refill, I would expect another $550 or so due with Lilly kicking in another $150.

Instead, for my first fill in January, Lilly paid for everything except $25 of the $1000 price. My insurance paperwork indicates that I paid for all of it and they deducted it from my deductible. For the second month, Lilly once again kicked in to cover everything except $25. Lilly doesn't seem to be doing their own $150 per fill limitation. So, with a couple other doctor appointments, I have already met my $1700 deductible from my insurance perspective, but Lilly covered about $1400 of that.

This same thing happened last year. However, later in the year, I did reach the annual $1950 limit from Lilly and had to pay a couple hundred for a refill. But all I did after that was request another coupon from Lilly. It had different numbers on it. I gave that to the Walmart pharmacy and for the rest of the year, I only paid the $25 amount. So Lilly was again kicking in their share.

This year, after the first 2 refills, I deleted the Lilly coupon from my online Walmart pharmacy account since it's almost maxed out already and got a new card with new numbers on it. I'm waiting for my March refill to make sure it all works, but it appears that Lilly doesn't track to an individual, but rather to the card number itself. And the cards are free to get from their website. Works for me.

You should check to see if your debit card has an annual max. And maybe try to get another one if that's possible.

Had I really trusted this system, I would have signed up for the cheaper plan with the higher deductible and let Lilly cover most of it. I wasn't that brave.

 

[CDRE]

My insurance company no longer applies the manufacture's support card towards the deductible or Out Of Pocket maximum. To circumvent this limitation, the manufacture provides reimbursements directly to me upon submitting proof of purchase to the manufacturer. The manufacture's maximum yearly support has not increased in four years so it no longer covers the insurance OOP maximum.

Regardless, the insurance company does not follow their "Evidence Of Coverage" document wherein it states that a Tier 4 drug must be paid 100% by me until the deductible is reached and then it is a 50/50 cost share until the OOP maximum is achieved. The insurance company has always paid some towards the drug in lieu of me paying 100%. Most likely the sole purpose is to extend the time frame until the OOP maximum is achieved, in their desperate hopes that medical cost other than supported by the manufacture will be incurred and thus requiring less funding from the insurance company.

Totally a cat and mouse game between the insurance company and the manufacture.