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Question:

From Huntingtown, Maryland, USA:

I have double coverage for my insurance, my primary being my dad's insurance policy, Alliance, and my secondary being my mom's insurance policy, CareFirst. There is no pharmacy card through Alliance, so, for the last 12 years, whenever I have needed my insulin, test strips, etc., we would just submit it to CareFirst and not have to pay anything but an $8.00 co pay. A few months ago, I went to pick up my insulin from the pharmacist and I owed $800 because CareFirst found out they were my secondary insurance and it is not their responsibility to pay for my medicine, it is Alliance's. Now I'm stuck in a situation where, whenever I need to pick up my medical supplies, I have to pay all the money up front and submit it to Alliance which they will then refund, paying 80% of the bill. I have battled between the two insurance companies and nothing can be done. Do you know of any program or anything at all that could help me in my situation? I'm a college student paying for everything myself and, now, on top of this, I have to come up with money for my medical needs, money that I don't have. I could not afford my insulin two weeks ago and am really afraid of running out of my supplies before I can come up with enough money to purchase it again.

Answer:

Your predicament raises significant issues concerning the coordination of benefits between the two health insurance coverages. A person who has coverage by more than one health insurer is required to notify each company of the existence of other coverage. In that way, each company measures the amount of coverage for a covered expense according to the terms of their group contract. And, the companies will determine between them which plan is the primary plan and which plan is secondary.

In this way, the bills for medical care and other covered expenses are submitted and paid by the primary plan first, according to the benefits available under its contract. The primary plan will then issue an explanation of benefit (EOB) to the patient showing the bills submitted for payment, the benefits available under the policy, how much of the claim was paid, and any remainder that is unpaid left to the patient. The patient then submits a copy of the original bill along with the EOB from the primary insurer (Alliance) to the secondary insurer (CareFirst). The secondary insurer will then pay any benefits available under its contract up to the full amount of the original cost of the service or expense that was left unpaid by the primary coverage.

In your case, Alliance, your primary insurer, provides pharmacy coverage. But, Alliance requires the patient to pay for the pharmacy item up front and reimburses after a claim is submitted. CareFirst, the insurer of your secondary coverage, would normally only require the payment of a modest co pay when you fill your prescription (or purchase your other eligible pharmacy item). But, because they are secondary, they want to see what Alliance would pay first, before they will determine what benefit is available for an otherwise covered pharmacy expense.

The solution to your problem is quite simple. If the coverage under CareFirst provides greater benefits than the coverage offered by Alliance, you should ask your father to drop you from his policy. You should then forward the notice of termination you will receive from Alliance to CareFirst to make sure they acknowledge that they are now your primary health insurer. However, before dropping the coverage from Alliance, make sure that the CareFirst plan will meet your needs. Would you be limited to a limited network of physicians? Do all of your doctors accept CareFirst or participate in their plan? If you are satisfied with how you would make out under CareFirst, then you might consider dropping the duplicate coverage.

To answer your original question: there is no assistance program that will benefit you because you have insurance coverage for pharmacy items. In fact you are fully covered, twice.

Full disclosure: I am employed by a health plan that is licensed and does business in the State of Maryland.

DSH

DTQ-20050908001805
Original posting 9 Sep 2005
Posted to Insurance/Costs

  
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Last Updated: Tuesday April 06, 2010 15:10:04
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