Re: New Blue Cross Fed drug program snafu

Carmie · ‎10-25-2010

@CelticCrafter Diabetic test strips are covered under the durable medical equiptment benefit under Part B of Medicare and not by the RX benefit.

In 2024 Medicare Part B has a $240 deductible. All outpatient services are covered under this benefit like office visits, emergency room visits and lab tests for example.

Once the deductible has been met, Medicare will pay 80% of the allowed charge. If you have a supplemental insurance plan, it will pay 20% so they will be covered in full.

Some supplemental plans do pay the Medicare B deductible, but those are no longer available to purchase if you became eligible for Medicare after January 1, 2020. The plans that cover the deductible are Plan C and Plans F and H.

I am guessing you have Traditional Medicare and a supplement that does not cover the Part b deductible, but will cover the 20% coinsurance.

If I had to guess what is happening in your husband's case, I would say the pharmacy did not send the claim in correctly. They either sent it under the wrong ID number or if he has an Advantage Medicare plan, the wrong insurance company.

I would check to see if they have the correct insurance information, and tell them to resend the claim. Test strips are covered if medically necessary under Traditional Medicare and Medicare Advantage Plans.

If your deductible hasn't been met yet, you will get an Explanation of Medicare Benefits statement telling you that.

I believe the fault is with the pharmacy. It is their responsibility to send the claim in correctly and I don't think they did. If a claim is applied to the deductible, it is not denied. You need to get credit for this since I am guessing you paid for the strips out of pocket.

The strips should either be applied to the deductible, or if the deductible has been met, paid at 80%. If you have a supplement, that insurance will pay the 20%.

I hope this helps.

Justice4all · ‎12-22-2013

@Kachina624 wrote:
@patbz. My group also changed to an outfit called Express Scripts (who ever heard of them?), and it seems to me like the co-pays went up. We had Optum RX and they were so good. This new group doesn't even offer non-childproof caps. I had to take a hammer to one bottle. They've already screwed up one of my meds.

We have Express Scripts. I use the pharmacy.

CelticCrafter · ‎03-09-2010

@Carmie wrote:
@CelticCrafter Diabetic test strips are covered under the durable medical equiptment benefit under Part B of Medicare and not by the RX benefit.

In 2024 Medicare Part B has a $240 deductible. All outpatient services are covered under this benefit like office visits, emergency room visits and lab tests for example.

Once the deductible has been met, Medicare will pay 80% of the allowed charge. If you have a supplemental insurance plan, it will pay 20% so they will be covered in full.

Some supplemental plans do pay the Medicare B deductible, but those are no longer available to purchase if you became eligible for Medicare after January 1, 2020. The plans that cover the deductible are Plan C and Plans F and H.

I am guessing you have Traditional Medicare and a supplement that does not cover the Part b deductible, but will cover the 20% coinsurance.

If I had to guess what is happening in your husband's case, I would say the pharmacy did not send the claim in correctly. They either sent it under the wrong ID number or if he has an Advantage Medicare plan, the wrong insurance company.

I would check to see if they have the correct insurance information, and tell them to resend the claim. Test strips are covered if medically necessary under Traditional Medicare and Medicare Advantage Plans.

If your deductible hasn't been met yet, you will get an Explanation of Medicare Benefits statement telling you that.

I believe the fault is with the pharmacy. It is their responsibility to send the claim in correctly and I don't think they did. If a claim is applied to the deductible, it is not denied. You need to get credit for this since I am guessing you paid for the strips out of pocket.

The strips should either be applied to the deductible, or if the deductible has been met, paid at 80%. If you have a supplement, that insurance will pay the 20%.

I hope this helps.

@Carmie Thanks, we think the pharmacy is doing something wrong too. We spoke to Medicare three times and all three times they told us they have no record of a claim.

I just said to my husband that when he goes back the pharmacy needs to resubmit it from scratch, not resend it, we seem to think they didn't enter his Medicare # correctly.

It should at least show up as being applied to the deductible, am I right? It would also show up in his on line account that the cost has been applied to his deductible.

NEvans2 · ‎01-15-2017

@Kachina624 Have your Dr. Office get a hold of them. It sounds like someone doesn't know what they're talking about.

Carmie · ‎10-25-2010

@CelticCrafter If his deductible has not been met for this year, it will be applied to his deductible and you will get a notice showing how it was processed.

It will show up on his records.

FancyPhillyshopper · ‎05-02-2017

I didn't bother reading this whole forum because after I saw the silly statement that said "he stopped taking the drug on principle." I started laughing.

Who endangers their health to prove a point to the increase in prices? No one at the headquarters cares if you don't take your medicine.

Just switch insurance companies if you do not like your benefits.

As a pet parent I have had to pay enormous sums of money for my pets' health--all out of pocket. One blood transfusion for my cat cost $1200.00, and I had to have ten of them for him to keep him alive when he had severe cancer.

Sixty dollars a month is nothing if it keeps you healthy. Just cut out some QVC shopping.

CelticCrafter · ‎03-09-2010

@FancyPhillyshopper wrote:

I didn't bother reading this whole forum because after I saw the silly statement that said "he stopped taking the drug on principle." I started laughing.

Who endangers their health to prove a point to the increase in prices? No one at the headquarters cares if you don't take your medicine.

Just switch insurance companies if you do not like your benefits.

As a pet parent I have had to pay enormous sums of money for my pets' health--all out of pocket. One blood transfusion for my cat cost $1200.00, and I had to have ten of them for him to keep him alive when he had severe cancer.

Sixty dollars a month is nothing if it keeps you healthy. Just cut out some QVC shopping.

@FancyPhillyshopper for starters you can't "just switch insurance companies".

Second, just because the OP posts here doesn't mean she should " cut out some QVC shopping".

I don't shop at QVC or HSN yet I post here...

patbz · ‎03-10-2010

@CelticCrafter : I buy maybe one purchase every year or so. Thank you for your response.

Nuttmeg · ‎03-09-2010

@Kachina624 wrote:
@patbz. My group also changed to an outfit called Express Scripts (who ever heard of them?), and it seems to me like the co-pays went up. We had Optum RX and they were so good. This new group doesn't even offer non-childproof caps. I had to take a hammer to one bottle. They've already screwed up one of my meds.

I had them for years. They are just another Prescription Benefit Management company like Optium.