Speciality Pharmacy/Insurance Being Unethical?

In California, I know things vary by state. My husband is on a daily medication to keep his cancer stable. This is not a new medication for him (going on year 10) but the brand name is a non-formulary medication. We have a prior authorization in place to have it approved.

When I called in April to order it, we have to go through our speciality pharmacy, which is all online/over the phone. They said the medications co pay was $2,993. We have never been charged more than $100, as our insurance policy states – Tier 4 – Typically Preferred Specialty (brand and generic) 25% coinsurance up to $100/prescription, Prescription Drug deductible applies (retail and home delivery), that deductible is $100 per person yearly.

So I questioned the entire thing. No one could figure it out. I got as high up as talking to resolutions. They also could not figure it out. They said we could join a cost Relief program, which I wasn't opposed too. But I did still want to know why this medication wasn't being covered. Next day they say we can order the medication and it was a $0 copay. So we do that. Next day comes, we get an urgent notification saying to call. Turns out it's back to the $2,993. And that we aren't able to join the cost Relief. But because they said $0 they will leave it at that because it was their bad. We get the medication, resolutions calls again says the test claim they ran said $100 for next month so we should be good.

Fast forward to yesterday. Go to order the medication again. Ordered on the website, said $0 copay. Woke up today to see urgent message, says cost is $2,993. I call them, they said the claim is actually $4,300. Once again I am frustrated and just like why? I read them my EOC and SOC benefits. They compared them to last year, nothing has changed. Pharmacy transfers me to insurance. Insurance rep. is trying to figure it out. She's going over everything, says it looks like a billing issue. Calls them, no help. Then she calls a few other departments, no help. Finally she calls the pharmacy back. And they helped her figure it out.

Turns out we had some past collections, amounting to $300 with dates in 2018 and 2020. They are with a seperate debt collector but appearently they put a block on our account and the insurance will not fully pay out the medications. I get upset, this is my husband's cancer medication. If I have collections somewhere I am sorry, and I will sort that out but that is not their business anymore. They sold the debt? She said the pharmacy billing department will let it through this month and do an override. Meaning the medication was ordered, $0 Co pay fully covered. Because we met our deductible already (good ole cancer). But they will not do this next month.

Is this ethical? We don't actually owe the pharmacy any money. They've never done this before. And why would the insurance underpay the claim? Collections should not dictate my coverage?

submitted by /u/mrsramirez50
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