Pharmacy techs/Pharmacists

[Luna Baby]

Those of you working in the pharmacy may be able to help me understand this. I take an RX for migraines-9 tablets dispensed at a time. Retail/cash price has been $700+ but my insurance has it listed as a $30 copay. The last 4-5 times I've had it filled, my copay was only $25 (brand new ins card still shows $30). Hubby takes a pill everyday that has been $7 copay for years. Yesterday, I picked up his refill and had my debit card out ready to swipe when the clerk told me it would be $0.01 How in the world has my copays went down so much? I usually know all the ins/outs of insurance, especially the plans that we're covered by, but this has me completely bumfuzzled.

I'm certainly not complaining as we have excellent coverage for very little premium cost to hubby. I'm just hoping they can't come back later and say they charged me too little and recoup later. Any thoughts?

[2gigch1]

Two things come to mind: if you were near the end of the year I would think that you had reached a milestone on medical expenses and the insurance was now picking up more of the tab.

Since it is now a new year there have obviously been changes in your plan since last year. I would certainly hop on the phone and start asking questions now before it gets ugly later. If you do catch a problem, you (and they) will appreciate it. If it's not an error then Yay! Worry free livin!

[Luna Baby]

Finally got an answer but I'm not sure I understand it. According to our plan, we met our maximum OOP and it has apparently carried over to this year. Looking at our RX claims online and the cost estimator, neither of us should pay more than $0.01 for our RX. Never had it to carry over like that before, but I do know that due to the ACA, a lot has changed with insurance that I've not had any dealings with before.

[sstabeler]

basically? there is a point at which insurance covers 100% of the tab for pescriptio meds.. you hit it for your policy, and for whatever eason, thta carries over to the next year.

In short, this year, you get meds w/o a co-pay.

[KuariKaydrith]

The way I understand it is that deductibles restart every year on January 1st, that it doesn't carry over. I know for the group that I provide benefit information for that there are three parts to how their coverage works - they have a deductible to meet and once that is met then it goes into a co-insurance phase where they only pay 20%, once they have paid out a certain amount during this phase then their medical and Rx coverage is covered by the company at 100%. But those are set back to zero at the start of every year.

I would seriously recommend confirming with your Rx provider so that you aren't in for any expensive surprises later in the year because none of the administrators we deal with have the deductible amounts carry over from year into the next.

[Luna Baby]

Thank you, KuariKaydrith. That's that way I've always understood it, too. One exception would be that deductibles not met until the 4th quarter do carry over in some cases. I'm assuming that is the case since we've only actually been able to start using our insurance this last year. Prior to that, we couldn't afford the deductible and 'toughed it out' on most things. I may go ahead and call since we are expecting to need extensive coverage this year with the eldest boy starting to actually use it as well. He will be starting treatment with a specialist soon and I'm sure that there will be some costly medications involved.