I think oncology Specialty pharmacy is charging wrong amount for oncology medication? Not sure, please see details below.

Health Insurance copay question

Female Age 49 State: Missouri

My oncology medication is non preferred Tier 4 drug on my insurance plan. I clarified with my insurance company today that the copay amount should be $200. However the oncology pharmacy was charging my pharmaceutical company copay card $2000 a month. More detail below with question.

My deductible was paid early this year. I was prescribed a this tier 4 medication before & after this. I have been taking it since 2017. Not a new drug. So I was in out of pocket pay time.

I was given a copay card for the medication that was charged a $2,000 a month copay by the specialty pharmacy. Also, I am in a state that does not credit copays to deductibles if that is an important detail.

After months of this, I called my health insurance company because I saw in new enrollment paperwork from last year that the copay should be $200. They confirmed that it is still $200 and didn’t change. I called the specialty pharmacy and confirmed they were charging $2,000.

Why were they on charging the drug companies copay card $2000? I did inform my insurance company that the Oncology Pharmacy did this a month ago. They said they would find out about it because I need to know what copay amount I will need to pay for my medication in January when the deductible/ out of pocket resets. I called again today, and someone was supposed to call me back because “lots of notes but one person one project policy.” I didn’t hear back.

⬇️ ⬇️ ⬇️ Question here ⬇️ ⬇️ ⬇️ Curious about opinions on this? What’s going on? Why were they up charging the copay card so much that caused me to run out of funds so early knowing the year when it was supposed to cover the whole year at $200 per prescription as a tier 4 drug?

The copay card helped me greatly to spread out my out of pocket cost over the year in past years, I was really surprised to run out of funds so early.

Additional information that were responses to a question in other insurance sub for all types of insurance. I posted the link to that post at the bottom of this post

⁠I have a group health plan from my (sort of previous employer – I’m on indefinite medical leave because I have stage 4 cancer and will be in active cancer treatment for the rest of my life, so disabled/terminally ill)

I am able keep coverage on the group plan because I am terminally ill, it is a union agreement. The insurance company shows I am insured on the same group plan I’ve had since 2009 when I started working at my employer. I’m basically on indefinite leave but pay the whole premium out of pocket and none of it is employer subsidized like it was when I worked. I pay the amount directly to the plan admin for my (previous bc not working but technically employer).

They show I am still eligible for group coverage as an employee because of union agreement. The premium is auto drafted from my checking account monthly because of the way it is set up. The employer is sort of a state agency for the state I live in. I’m trying not to dox myself, not that I’m sure it matters, but maybe it does?

2. ⁠The pharmacy is in network, it is the pharmacy the insurance company specifically told me to use, and the only pharmacy they would allow me to use.

3. ⁠The pharmacy files the claims on my behalf directly with the insurance company

4. ⁠this medication required pre authorization, I got a letter it was pre approved for 99 years in 2017. From years 2017-2116. I have been taking it for over 7 years. This year I got a new letter that says it’s pre authorized for this new specialty pharmacy until May 2025.

5. ⁠I don’t receive EOB’s for prescriptions, but I do have an app that I can log into for pharmacy benefits. The soon does not show dollar amounts for this medication. It only shows the following

*approved to fill

*pre authorization beginning & end dates

*prescribing doctor

Number of refills left

date filled

I have a separate app for EOBs for medical claims that does show dollar amounts but only for medical claims, not pharmacy claims.

I was using a different pharmacy and the cost was $200 a month from 2017 until February of 2024 when the insurance company got a different contract with a different specialty pharmacy. At that time, they required me to switch to the new pharmacy this post is about.

The pharmacy is a specialty oncology pharmacy and there is a limited number of them in the USA that carry this cancer medication.

I have far out lived my prognosis. I have been an exceptional responder to this specific drug that usually lasts about 2 years before it stops working for patients, for some reason it’s still working for me.

​ Originally posted at https://www.reddit.com/r/Insurance/s/zlu9JN8OIK

There are some screenshots in reply to questions there that show my pharmacy app with my identifying information marked out/covered up.

Thank you if you made it through all of this! It makes a huge difference for me if I will pay $200 or $2000 a month for this medication. I have been in touch with an advocate who referred me to someone at the insurance company but it’s been a month and 3 calls and still no answers.