Can I get MS prescription filled before losing my insurance plan?

August 1, 2016 3:33 PM

Hello all, I can't find this answer anywhere (without directly asking my insurance company). My wife has multiple sclerosis, and without insurance her medication costs $6k per month. On our current plan I play $30 for a 3 month supply via the specialty pharmacy home delivery. We are losing this coverage at the end of August, but have a delivery in progress and will receive the next 6 months worth before we lose coverage. Is there some way they can charge me for the medication already received if I lose coverage for the following months?

To expand on the question, I have already signed up for an ACA plan beginning September 1st; however we will be leaving the country for at least 4 months on September 7th and would like to have the medicine in hand rather than attempting to obtain it from the new insurance provider in such a short time frame.

I obviously do not want our current provider to send me a bill for $30k. Any experts out there or anyone with similar experience?

Thanks.....

posted by fumbducker to Health & Fitness (12 answers total)

In general, I would expect to pay (or be billed for) medication when it is dispensed. Is that not how this usually works for you? Are they sending it to you now but you expect to be billed monthly or something?
posted by brainmouse at 3:40 PM on August 1, 2016

Anecdotally, I changed insurance a few years back and there was nothing like this for any of my 3 month prescriptions.
posted by soelo at 3:58 PM on August 1, 2016

Insurance companies can and do back charge. When we went on ACA, I cancelled my BCBS policy, effective June. BCBS decided it was effective January. So, I got some bills from providers and a refund for 6 months from BCBS. Since I came out ahead, I did not fight it.
I talked to one of my doctors, what the Ins. Co. does is take that amount out of future payments to the provider, so the provider has to go after the patient.
posted by rudd135 at 4:00 PM on August 1, 2016

I might ask a pharmacists at CVS - they tend to be super friendly. But, I would not think so. Because they are billing you at time of service. Can you ask your Dr?
posted by Boyd at 4:13 PM on August 1, 2016

Response by poster: Interesting. Soelo's & Brainmouse's responses are what I hoped and expected to hear. Rudd, your experience is a bit more concerning, but seems like it pertains more to medical bills than prescriptions that have already been dispensed.

Brainmouse, I have paid the co-pay for the medication today, which was $60 for the next 6 months, to be delivered Friday. I'm just nervous as the list price for that medication totals $38,000.
posted by fumbducker at 4:15 PM on August 1, 2016

Response by poster: Thanks for your response Boyd. We will certainly ask our doctor and have an appointment on Friday. I tend to try and gather as much information as possible, sometimes doctor's don't know, or think they know....
posted by fumbducker at 4:16 PM on August 1, 2016

Some (most?) insurance companies only care if you are covered when you purchase the prescription. I've switched insurance a handful of times with several months worth of prescription drugs on hand, no problem.

The situation rudd135 described is different - in that situation, rudd135 received bills for the time period she/he was (retroactively) not enrolled in insurance.
posted by insectosaurus at 4:18 PM on August 1, 2016 [3 favorites]

If you've been billed, your insurance has been billed (and paid), and you paid, you're done. They don't care when you take the med, they care when it gets billed.
posted by brainmouse at 4:38 PM on August 1, 2016

If there were less money on the line, I'd lean towards the combination of common sense (insurance is based on when the service is billed, the service is the dispensing of the drug), and it not being worth an insurance company's time to track down a $70 reimbursment to say you probably have nothing to worry about.

But at $38,000, I could see this being the level of things that even a large health insurance plan would bother to audit every now and then. And if the plan terms do say something like "we cover medication prescribed for the plan's coverage period" maybe they might chase you for it.

Barring an insurance claims processor or a lawyer who deals in health insurance law speaking up here, I think you need to talk to someone in the know. I understand why you don't want to call your current insurance provider about this, but why don't you call your ACA provider? If the general "standard" is for the insurance company to pay for the medication prescribed for the coverage period, then your ACA provider should logically be on the hook for the medications starting in September. Call them and ask them if this is a thing you need to worry about, and if so, how that reimbursement might happen.

Maybe in that conversation, the ACA provider might drop the right buzzword on you (I'm thinking something super insurancey like "abrogation") and you can call your current provider without giving all your details to ask the general question, something like "If I'm on X plan, and I terminate would you expect [abrogation] of the payments made to the pharmacy for medicines prescribed for after the plan ends?"
posted by sparklemotion at 5:14 PM on August 1, 2016

If you've been billed, your insurance has been billed (and paid), and you paid, you're done. They don't care when you take the med, they care when it gets billed.

This. Unlike just about every other medical service, prescriptions claims are settled before treatment. If the insurer wanted to claw their money back somehow, they'd have to bill you for it.

(This is why Medicaid, at least in my state, only allows 30-day refills.)

I'd recommend asking your pharmacy about this. They've likely seen it all with regards to prescription billing.
posted by neckro23 at 6:50 PM on August 1, 2016 [1 favorite]

If it helps, it is, as far as I know, absolutely standard to request that prescriptions be filled early because you are traveling.

If your inquiries turn up bad news, ask about your new insurer paying for them. If you are covered in October, whoever covers you should be paying for it.
posted by oddman at 9:13 PM on August 1, 2016

Response by poster: thanks everyone for the advice, seems like the consensus is what i thought. i think i wil make a discreet inquiry without identifying myself.
posted by fumbducker at 6:33 AM on August 2, 2016