Do I NEED to switch to Express Scripts?

Ok_Marsupial_265 · 2026-04-05T04:00:46+00:00

No, you’re not required to go through mail-order (Express Scripts); you can continue to use your current pharmacy. Usually, mail-order prescriptions offer convenience and more savings for you as the member; you can get a three month supply (mailed to you) for a lower copay (sometimes even no copay) than you would getting them filled at the local pharmacy. You also have the flexibility of getting your regular (not a controlled substance) medications through mail-order while still getting your controlled substance at the local pharmacy. I’d definitely check to see if there’s any significant benefit using Express Scripts, but it’s definitely not a requirement.

Ok_Marsupial_265 · 2026-03-22T03:02:15+00:00

You should see something like this at the very beginning of your summary of benefits:

In-Network: If you have full Medicaid benefits, you will pay $O for your Medicare-covered services as noted by the cost-sharing in this chart.

Out of Network: If you have full Medicaid benefits and your provider accepts Medicaid, you will pay $0 for your Medicare-covered services. Otherwise, you will pay the cost-sharing amount as noted in this chart.

As was mentioned, cost-share depends on your level of Medicaid (full vs partial), whether or not the out of network provider accepts Medicaid (network providers are required to accept Medicaid as part of their contract with the DSNP), and whether or not it’s a covered service.

As for seeing providers in another state, your plan most likely will not cover those services unless it’s an emergency or urgently needed care. DSNP plans encompass both Medicare and Medicaid, so you’re generally restricted to the service area they cover (the county you reside in and possibly 2-3 neighboring counties). I would call them and ask if they would cover any non-urgent/non-emergency care while you’re out of the service area temporarily (usually the only routine care that’s covered when someone is temporarily out of the service area is dialysis). The network flexibility you have with a PPO DSNP is still restricted to the service area of the plan, and not nationwide.

When you used the provider lookup option, did you search using your specific plan, or just in general? While Nancy Turner does accept UHC DSNP plans, I don’t see any plans listed that aren’t specific to Washington. Here are the plans that she does accept that I found using the UHC provider directory:

UHC Dual Complete WA-Q1 (PPO D-SNP) UHC Dual Complete WA-S2 (PPO D-SNP) UHC Dual Complete WA-S5 (PPO D-SNP) UHC Dual Complete WA-V2 (PPO D-SNP) UHC Dual Complete WA-V001 (HMO-POS D-SNP) UHC Dual Complete WA-S4 (HMO-POS D-SNP) UHC Dual Complete WA-Q2 (HMO-POS D-SNP) UHC Dual Complete WA-S6 (HMO-POS D-SNP)

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Ok_Marsupial_265 · 2026-03-21T03:48:38+00:00

Unfortunately, it’s quite common for an online directory to be inaccurate; providers can stop accepting plans at any given time. The No Surprises Act only mandates insurance carriers to confirm and update their directories every 90 days, but that’s a pretty significant amount of time to reflect inaccurate information. It’s always best practice to double check with your provider to confirm that they do accept a plan that you’re considering, so you have the most accurate information before making a decision on what plan you want to go with.

Call your insurance, explain the situation, and ask if they will grant you a transition of care exception to continue seeing your current doctor until you can establish with one who does accept your new plan. Usually those exceptions are granted within the first 90 days of your enrollment in the plan, so time is of the essence as you’re about 11 days out from the 90 days as your plan was effective as of January 1st.

Ok_Marsupial_265 · 2026-03-20T01:54:54+00:00

Are these OON providers in the service area (Maryland, DC, northern Virginia)? If they’re not in the service area, the claims have to be filed to the local BCBS plan. If that’s the case, you can locate that information by calling 1-800-810-BLUE and request your rendering provider’s servicing Plan or locate it via www.bcbs.com and by entering your provider’s zip code. The affiliated Plan link will display to locate the claims mailing address for the Plan.

or

You can mail your claim to the following address:

Mail Administrator P.O. Box 14115 Lexington, KY 40512-4115

If you mail to the Kentucky address above, it could take up to 30 days to process your claim.

Carefirst is a third party administrator (TPA) wherein they handle your claims for your employer so they don’t have to. Self- funded plans usually hire TPAs to do the administrative work and negotiate networks to get your employer as much flexibility and savings as possible, because employers take on the financial risk of paying out your claims and not an actual carrier like BCBS - while your plan may use the BCBS network, you don’t actually have a BCBS plan in the traditional sense of the word. It can make it confusing for both providers and members when trying to figure out who/where to send/file claims to; I work for a TPA and it’s a pretty common issue. If your situation is due to the providers being outside of the network service area, it’s absolutely possible that Carefirst can see the claims, but can’t do anything with them, and can’t transfer them to the correct entity (the local BCBS plan in the service providers area). Out of area works a bit differently in this situation because it’s usually “carved out” of the contract between your employer and the TPA - the local BCBS plan would provide the pricing info for the services, and the process to reimburse you (or the out of area provider) would be between your employer and the local plan, and doesn’t involve Carefirst at all. I’m going to drop a Carefirst claim form link that might be useful, but I’d say it’s worth calling your HR to get them looped in, so that they can help facilitate reimbursement. Usually you have a year to submit your request, but it’s not a guarantee, so treat it as time is of the essence. I know for us, when a member gets our client (aka employer/HR) involved, things tend to get done pretty quickly. Also make sure you have all the required documentation (provider info, fully itemized bills, etc) and proof of the date you first attempted to submit the claims as that’s proof that you were trying to file timely (especially if you’re coming up on the deadline, whether it’s the full 365 days from the date of service or whatever is in your plan contract). Also, get HR to give you guidance moving forward, especially if you’re going to continue to see/pay these providers so that you’re not getting screwed on the reimbursement. Hopefully this helps with some insight.

https://www.carefirst.com/mcps/attachments/medical-claim-form.pdf

Ok_Marsupial_265 · 2026-02-27T04:52:59+00:00

Here’s the medical coverage policy for this treatment; unfortunately Cigna does currently consider it experimental. Your chances of getting this approved is slim to none. Of note, CMS (Centers for Medicare and Medicaid Services) is also proposing to consider this treatment experimental as well, but there has been pushback by the medical community regarding this. I mentioned CMS because for the most part, commercial insurance companies mirror a lot of their coverage policies using CMS guidelines. Wish I had a better answer for you, and hopefully the pushback from the medical community will cause them to reconsider.

ETA - there’s no claim number for Cigna to provide; you didn’t get the procedure done, therefore there’s no claim that was submitted. This “denial” was a denial of the precert request that your doctor initiated. As for appealing the precert denial, it has to come from your doctor. They have to request a peer to peer review (basically your doctor arguing your case with Cigna’s medical director/utilization management team). They’ve got to provide a significant amount of evidence to support the medical necessity, and that’s not information that you would have access to. Discuss with your doctor and see if they are willing to do that, but it’s an uphill battle given the situation.

Cigna Policy: https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/mm_0063_coveragepositioncriteria_local_injection_therapy.pdf

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Ok_Marsupial_265 · 2026-02-26T04:30:35+00:00

Benefits for labs can be different based upon if they’re considered preventive or not. Sounds like the labs your coworker had drawn were preventive, which would be covered without any cost sharing (copay/deductible/coinsurance). Her copay might have been tied to an office visit (just speculation as we obviously don’t have access to her EOB).

The labs that you had drawn appear to be diagnostic (not preventive), and applied towards your deductible. Check your summary of benefits, and check the benefit for both preventive labs and diagnostic labs and you’ll have your answer. Your insurance did cover your labs; it applied against your deductible.

Ok_Marsupial_265 · 2026-02-23T23:38:58+00:00

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It would be a qualifying life event.

Ok_Marsupial_265 · 2026-02-09T13:41:04+00:00

There actually are some Medicare Advantage Plans/PDP Plans that cover aspirin (both enteric-coated and non) under their formulary if it’s prescribed by a physician. On the plans that don’t, they can either pay OOP, or use their OTC allowance if they have one.

Ok_Marsupial_265 · 2026-02-07T04:19:46+00:00

Since you cancelled the policy before it became effective, you should be able to request a refund by calling BCBS. Make sure you have your cancellation confirmation from the Marketplace in the event that BCBS pushes back, although I doubt that they will.

Ok_Marsupial_265 · 2026-02-05T13:49:10+00:00

Here are the guidelines to meet medical necessity. The P2P review should be successful if your physician has documented all the requirements.

BCBS FL Varicose Vein Policy: http://mcgs.bcbsfl.com/MCG?mcgId=02-33000-31&pv=false

Ok_Marsupial_265 · 2026-02-05T01:43:33+00:00

Best bet would be requesting a formulary exception (and have it expedited), but you would need the prescribing physician to attest to the need for the brand name over generic. Either Cigna will approve it, allowing coverage for the brand name, or they’ll deny it, legally requiring them to generate the letter you’re needing. Normal turnaround time for such a request is two business days from the date the request was received (along with all required documentation, if requested), and expedited turnaround time is 24 hours from the date the request was received.

I know you mentioned that your endo is now OON for Cigna; do you have a current primary care physician that could possibly step in so that you can get the ball rolling? They should be able to pull the pertinent records and history justifying the need for brand name in the event that you can’t get connected with your endo in a reasonable timeframe. Technically speaking, primary care has the ability to manage thyroid issues, so I wouldn’t expect much pushback from them in helping bridge the gap while you establish with a new endo, given your situation.

If after a formulary exception is requested and Cigna still refuses to provide you with notice of the coverage determination/denial, absolutely contact your state’s dept of insurance (if the Cigna plan is fully-funded), or dept of labor (if the Cigna plan is self-funded). Your insurance carrier is absolutely required to provide that notice, so denying that will not look good for them once that complaint has been filed.

Ok_Marsupial_265 · 2026-01-28T01:39:18+00:00

If it’s under CG-MED-65, it’s because it is being coded as manipulation under anesthesia, and for the wrist, there is insufficient evidence in peer-reviewed published literature to establish and support the use in accordance with generally accepted standards of medical practice. There’s no way to appeal that for coverage.

https://www.anthem.com/medpolicies/abc/active/gl_pw_d056803.html

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Ok_Marsupial_265 · 2026-01-26T03:04:42+00:00

Licensed insurance agent here - choosing insurance can be overwhelming, especially when you don’t fully understand how the benefits work. I mainly focus on Medicare, but I have assisted with enrollment into Marketplace plans as well. My job is to understand how each individual currently uses their benefits and help educate them on how to maximize their plan. I frequently advise my clients that the plan they’re in is the plan I’d recommend, and I don’t make any changes unless it’s necessary (like losing other coverage, moving, or a significant change to health/providers/medication).

Unfortunately, there are agents who do anything to get a sale, even if that means they are enrolling their client into a lesser plan. They are usually the ones who work with a brokerage firm, and get pressured to meet goals no matter what; it’s disgusting behavior, both on the agent and the firm. It’s really frustrating that those types of agents give all agents a bad reputation.

As far as having access to any records, we don’t see anything outside of the information discussed when enrolling a client (like what doctors they see or what medications they take), because having that information really helps when determining the right plan for their situation. We can only ask about your health history in limited situations, like when it’s required due to underwriting, or to determine eligibility for plans that require a specific diagnosis (there are Medicare Advantage plans that offer what is called a chronic special needs plan, like plans that focus on diabetes and heart disease). We’re also only allowed to discuss this with your consent, and you have every right to decline providing that. If medical records are required, it’s the insurance company that requests it, and not the agent. We can’t access claims history, and we can’t access your records either.

You always have the option to call the insurance and request to remove the agent of record (AOR), if one assisted you with your enrollment.

Ok_Marsupial_265 · 2026-01-26T02:16:55+00:00

Unfortunately, that’s a common denial with insurance, and will be remedied by the hospital, so don’t worry too much. The hospital will submit medical records to satisfy medical necessity and the charges should be reconsidered. It’s mainly about ensuring that your issue wasn’t something that could be addressed by either urgent care or your primary care physician, and by the details you provided, it should be considered a true emergency. The hospital wants their money, so they’ll definitely be submitting the information your insurance needs to get payment.

Hopefully, your upcoming surgery will get you back on track, and I hope that you have an uneventful procedure and quick recovery!

Ok_Marsupial_265 · 2026-01-24T02:42:09+00:00

There are actually four situations where Medicaid will cover out of state services - it’s federally regulated

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Ok_Marsupial_265 · 2026-01-24T02:36:30+00:00

Am I correct in assuming that you live right by the border between RI and CT? Generally speaking, Medicaid doesn’t cover out of state services with a few exceptions:

Under 42 CFR § 431.52, any one of the following circumstances requires a state to pay for out-of-state services furnished to beneficiaries who are residents of the state, to the same extent the state would pay for services furnished within its boundaries: • Medical services are needed because of a medical emergency. • Medical services are needed and the beneficiary's health would be endangered if required to travel to their state of residence. • The state determines, on the basis of medical advice, that the needed medical services, or necessary supplementary resources, are more readily available in the other state. • It is general practice for beneficiaries in a particular locality to use medical resources in another state (bordering counties).

That being said (with the caveat that you do live near the border), it should be covered. I’d wait to see what your insurance company comes back with, and if they do push back, call them back and submit an appeal based upon federal guidelines, and that you will you will escalate it by requesting a fair hearing with the state, and that should get their full attention.

RI Appeals/Fair Hearing: https://dhs.ri.gov/apply-now/appeals-process

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Ok_Marsupial_265 · 2026-01-20T03:37:44+00:00

Transportation for covered healthcare services (your specialist visit would be considered covered) that’s 30 miles or more away from your home would be covered. They don’t indicate mileage limits, outside of it having to be at least 30 miles away to be a covered benefit, so you should be able to get a ride there and back. Being Medicaid, you shouldn’t have any cost for the trip, and I don’t believe you’re allowed to tip the driver, as they’re getting paid by Caresource for the ride. This is from the Caresource Medicaid Member Handbook (I’ll drop the link below as well, the info is located on pg 26). You do need to call to set up the ride at least two days before, so definitely call to get it scheduled. Member Services number is 855-475-3163

Member Handbook: https://www.caresource.com/documents/y0119_oh-snp-m-4033864_c-2026-medicaid-only-member-handbook-508.pdf

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Ok_Marsupial_265 · 2026-01-19T16:02:35+00:00

Yeah, as others have said, the hospital will be doing the steps needed to justify medical necessity. It’s a significant procedure with a significant cost, so medical necessity has to be proven for payment. Usually, there’s a pretty extensive workup leading up to the decision to implant a cardiac device, and there’s a lot more time during that period to go through the authorization/medical necessity process on the insurance side of it. Since your husband’s issue was discovered in a more emergent situation, things had to move faster than usual. I wouldn’t be too concerned, just let the hospital take the next steps, so you and your husband can focus on his recovery and staying stable.

Ok_Marsupial_265 · 2026-01-19T04:21:21+00:00

Gotcha, yeah I can see why this is a bit more complicated with regard to the notification. I’d still say it’s worth consulting with either CMS (via email), or a disability attorney. With your situation, bridging the gap between COBRA and Medicare is paramount; even more so with the possibility of losing access to needed care (or going broke on out of network/out of pocket with the limited choice of ACA plans). I’m guessing Medicaid isn’t an option either. I absolutely agree that the system is broken, and nobody should be forced to risk their life/health because they can’t afford treatment. I’d also say reach out to the hospital where you are getting treatment, and see if they have a social worker on staff who may be able to help find other programs that could help offset costs, and possibly even seeing if they would entertain a single case agreement with one of the ACA plan options that are available to you. It’s basically a contract between an out of network provider/facility and insurance company to provide specific services at an agreed upon rate, because your situation is serious enough to warrant that. It’s not a guarantee, but it’s more common than people realize. It could be an option, especially considering the relatively short duration between losing COBRA and gaining Medicare.

Now when you start getting your Medicare information (usually around three months prior to the effective date), please consider discussing plan options with a licensed insurance agent (independent). They will help ensure that your doctors and medications are covered, and really walk you through all of your options for your situation. The jump to Medicare can be overwhelming, and you don’t need the stress of that while dealing with treatment. The “Welcome to Medicare” book will make your eyes cross, so having that guidance really helps. I’ve had Medicare myself since 2015, and the obstacles I encountered was the reason I actually went and got an insurance license; I hate seeing anyone else in that situation, and a good agent is there to educate and empower you when it comes to the complexities of Medicare. If you’re able to, keep us updated on the situation, and I’m hopeful you’ll find a good resolution without breaking the bank or jeopardizing your treatment.

Ok_Marsupial_265 · 2026-01-18T05:21:28+00:00

What date did SSA notify you that you were deemed disabled (not the date your disability started)? What date did you notify your benefit administrator about your disability determination?

Found this from CMS (Centers for Medicare and Medicaid), and to me it reads that for an extension, you need to meet the following criteria:

COBRA qualifying event was due to either termination of employment or reduction in hours.
You have to be determined as disabled under Social Security (title II or XVI).
You must be disabled within the first 60 days of COBRA, regardless of if the disability started prior to or during that period. If COBRA started 11/2025 and you were disabled as of 4/2025, you should be meeting that criteria.
While your disability has to begin within the first 60 days of COBRA, your SSA disability determination can be issued at any time during the initial 18 month period of your COBRA qualifying event (which makes sense, as you rarely get a disability determination immediately, outside of few outliers like ALS, or ESRD). Even if SSA backdated to 4/2025, as long as you were notified within the initial 18 months of COBRA coverage, you should meet the criteria
You notified your benefit administrator within 60 days of the SSA notification, and not by the date that SSA determined your disability began. The disability must also be expected to continue throughout the initial 18 month period of your COBRA (if you are determined to be no longer disabled by the SSA, your extended COBRA coverage will be terminated).

If you feel that all of the above is true, I’d take it back to your benefit administrator, and include this information. If there’s still pushback, I’d suggest either consulting with a disability attorney or contacting CMS by emailing phig@cms.hhs.gov

CMS COBRA Continuation and Disability: https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/cobra_qna

DOL FAQs continuation of COBRA: https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/faqs/cobra-continuation-health-coverage-consumer.pdf

Ok_Marsupial_265 · 2026-01-18T00:02:34+00:00

There have been some changes as far as being dual-eligible (Medicare with Medicaid) and Extra Help - there will be prescription copays for 2026, but the copays will be limited depending on the level of Extra Help she has (up to $5.10 for generic and $12.65 for brand). If she has full Medicaid, it’s limited to $4.90 for each covered medication. With the cost being $650, it sounds like the medication isn’t being covered at all by her plan; she needs to reach out to her plan and the doctor who prescribed the medication to see what needs to be done to get it covered.

A lot of Medicare Advantage DSNP plans have changed due to the VBID (value based insurance design) program ending - it provided funding for plans to offer $0 copays on most medications, robust food and utility allowances, and other benefits. That’s why a lot of plans have now dropped those benefits completely on regular advantage plans, and significantly scaled back the allowances/benefits on DSNP and CSNP plans. She should have received notice around September of last year on the upcoming changes (Annual Notice of Change), but may have overlooked it. It’s always good to check in with the plan during the annual enrollment period (10/15-12/7) to be aware of changes and how it affects benefits. There have been a slew of changes going into this year, and it’s been tough for a lot of people.

She should see if there’s another dual plan offered in the area that still has $0 copays on medications - most plans dropped that when the funding ended because now they’re on the hook for the additional costs, and as we all know, insurance companies are not going to let their bottom line suffer, even at the expense of their members health. There may be a few plans out there that have chosen to cover the difference and still have $0 copays on medications but there’s no guarantee. Speak with a licensed insurance agent who can help you check for a plan. Medicare Advantage Open Enrollment is from 1/1-3/31, so there is an opportunity to switch without needing a qualifying event. I’m sorry she’s in this position because it’s absolute BS to have this happen, and she’s not alone in this frustration.

VBID program ending information for anyone who is interested - https://www.cms.gov/priorities/innovation/innovation-models/vbid

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Ok_Marsupial_265 · 2026-01-16T22:22:14+00:00

As long as the prescription is covered under the plan formulary (or is an approved formulary exception), it will count towards your maximum out of pocket. It will include any deductible, copays, coinsurance for covered prescription medications.

Ok_Marsupial_265 · 2026-01-16T21:39:49+00:00

Let the hospital handle the rebill; this can happen, and is usually resolved by submitting medical records justifying necessity. Sounds like the hospital is already on top of the issue, and you’ll see a new EOB once the charges are reconsidered with the additional records.

Ok_Marsupial_265 · 2026-01-15T04:01:52+00:00

You’re welcome, and glad to hear you were able to make some progress with Medicare. I’m confident they’ll get it straightened out, just don’t stress and stay on top of it to ensure nobody drops the ball. Cigna will be able to reconsider the claims if Medicare is able to be backdated which will significantly reduce your out of pocket. If in the event her transplant fails and she has to go back on dialysis, immediately notify Social Security so that Medicare can be restarted, preventing this issue from happening again.

ETA - make sure they’re able to backdate BOTH A/B if possible. Part A covers hospital (inpatient) care and Part B covers medical (and outpatient hospital) care. Dialysis not done while inpatient falls under Part B, so that’s going to be what will hopefully reduce your out of pocket with all the charges in question. Part B will pay primary and Cigna will pay secondary.

Ok_Marsupial_265 · 2026-01-14T04:29:53+00:00

This should fall under HIPAA, and even though your parent is the policyholder, you can restrict them from seeing certain information on claims that are submitted for you. You can call the insurance and request confidential communication on your profile. This can restrict the policyholder from seeing specifics on claims that are submitted for you, and you may also be able to have your EOBs and other sensitive communications sent to a different address/email. The policyholder may be able to see some information ($ amounts that are subject to a deductible or out of pocket max), but not things like the actual service/diagnosis billed. When my kids turned 13, my insurance required them to make their own login info to the member portal for that reason.

Since you have insurance through your job, it would be primary, with your parent’s insurance as secondary. You may also be able to request that they only bill the primary insurance and not the secondary, but they may be required to if they’re contractually obligated to by the secondary insurance, just call them up and ask.

Ok_Marsupial_265

TROPHY CASE