My wife’s work also has a prescription coverage through her work— which apparently by default makes it my secondary.
They have different formularies.
For example. My primary plan covers novolog. The secondary plan covers humalog. My primary plan covers accuchek stips, secondary covers lifespan. I can’t directly bill the secondary through my pharmacy… so I have to submit paper claims I guess?
So if I get an rx for novolog and accuchek strips and pay my primary’s $75copay for each —- then submit that to my secondary through the mail— what happens?
@Sam, I am in a similar situation, and have to submit claims after the fact to my secondary for reimbursement. It’s a hassle, and they try to fight me on payment, but I usually win in the end. Tenacity is the key.
That’s basically what I came up with after several phone calls.
What’s still confusing to me is what if the item is not on formulary—-
Eg primary covers novolog secondary covers humalog. They told me they will honor the primary’s formulary as long as it’s not an “excluded benefit” she used the example of “if your primary covers weight loss drugs but we don’t— we could not cover your copay—- but if your primary covers novolog and our formulary option is hunalog we would reimburse your copay”
It doesn’t matter; you have two insurance policies covering the same risk. Normally that would mean you can claim on both, e.g. you die; both insurance policies pay, e.g. you get sick and can’t make a really big business deal, both insurance policies pay, though they might start investigating whether you deliberately got sick. E.g. your ship sinks, or (the modern equivalent) your golf course gets gophers; both insurance companies pay, after a lot of really close examination of gopher butt.
If the payout is covering the cost of the medication then it will be written to cover the cost to you; this is in the nature of the corrupt place we live because the cost to you can be way higher than the actual cost because of kickbacks to the insurer. So that makes it more complicated; if you have two insurers you have two sets of kickbacks, only one of which is likely to get paid, and so on.
So what you do is go to a second pharmacy and register with that pharmacy using the other policy (I’m guessing your wife’s) and then you check the costs on both before filing the prescription with the cheapest.
You are entitled to claim on either, like, duh; taking out a second insurance policy doesn’t invalidate the first one! The pharmacist should be able to run it through both policies, but don’t ask, just fix it.
Then, if you want to, having obtained the greatest good, sure, fill in the paperwork, however I don’t see how it can reduce your costs because it is out of network (simply because you went through the other insurance company, so you didn’t pay this insurance companies kickback.)
That was my understanding until today… I asked my doc to send the rx to my wife’s plans mail order pharmacy because it had zero copay. They called me and said that they couldn’t process the claim until my primary had been billed first “because they could see that there was another primary plan and that they were the secondary coverage”
The customer service pharmacy rep said that I need to call the insurer (my secondary— my wife’s) and say that I no longer had the primary plan in order for them to process (which wasn’t accurate). I wasn’t comfortable with that because it seemed fraudulent.
After several more phone calls they said I need to go through primary plan first then mail them the itemized receipts that show the copays and they’ll process accordingly…
This wasn’t Walgreens was it? I had the same problem with secondary coverage obtained from Eli Lilley for my humalog; the first person I spoke to at Walgreens didn’t know how to bill it. Eventually they worked it out and I got the insulin for $100/month.
The pharmacy can for sure bill two insurers; Walgreens did for me. The Eli Lilley discount I had was co-insurance, i.e. Eli Lilley were explicitly secondary (“co”) insurance. I guess your wife’s policy will probably be written the same way; co-insurance in the event that you don’t have any, but the pharmacy should still be able to bill it.
The telephone reps jobs is to get rid of you. Lying to you is acceptable, indeed, expected; their training quite deliberately doesn’t tell them the truth so they can’t tell you the truth. They are also permitted, probably encouraged, to persuade you to break the law. So far as I can see this is not illegal. Pharmacy mail order companies and pharmacy benefit managers are particularly problematic; it is not unreasonable to assume that everything they tell you is a lie. Certainly they lied to my wife about straightforward factual matters, e.g. lying about either receiving or transmitting information to my insurance company; either they lied or my insurance company did, but the latter has at least a veneer of truthfulness.
That said, it comes down to the stress-hours Dealing with this stuff even got my wife angry to the point of not being able to go on with the interminable telephone calls. I’ve never had her patience.
Apparently it’s not that simple… sometimes they can. Sometimes they’re not set up that way…
Some insurance plans have retail contracts it seems—- I was able to bill my wife’s plan for a 1 month supply at a retail pharmacy (yes it was Walgreens 2 time limit)… but not a mail order for a 3 month supply…
I’m hopeful that I have this figured out for this time but it won’t be clear until after I mail in the receipts to my wife’s plan and see what they say (of course that’ll take weeks at least).
On the bright side I’m really glad that my new healthcare provider (diabetes specialist NP) has been 100% responsive (same day) with all this bs runaround and has sent exactly what I’ve asked for towherever I’ve asked her to send it… couldn’t have asked for a better doc support even though it’s been a runaround with the pharmacies
I’ve encountered the inability to Bill a secondary plan at both retail and mail order pharmacies with multiple plans— there are complexities involved as to who is in contract as primary and as secondary… @Tim
Dealing with this stuff even got my wife angry to the point of not being able to go on with the interminable telephone calls. I’ve never had her patience.