What is the statute of limitations for reimbursement for prescription drug copayments?

Question

My daughter has special needs and requires several different medications. She is on medicaid and another insurance, which until last year, I didn't know would pick up the copayments. So for a whole year (from the time she turned 18 until she turned 19) I was paying the copayments for her (now her other insurance is paying the copayments). The pharmacy knew my daughter was on this other insurance and never mentioned that it would pick up the copayments. When I did find out from a doctor friend of mine, I tried to get reimbursement for the copayments through the other insurance, but they say I have to do this through the pharmacy. The pharmacy says it's been too long now for us to be reimbursed and I am wondering what my daughter's rights are, since we were only made aware less than a year ago. We payed out several hundred dollars in copayments over that one year.

Answer 1

First of all it is NOT the pharmacy's responsibility to determine which of your insurances pay what. That is yours solely. Secondly, the Pharmacy is not able to keep track of what the thousands of insurances out there do and don't cover. They bill what and who you direct them to....no more. Their responsibility is to insure that you receive the proper medicines, make sure the dosage is proper, make you aware of potential interactions and side-effects, and maintain records. How you pay for them is your problem.

Now, that having been said, how do we go about getting your money back? Because it sounds to me like you definitely got worked over by your secondary insurance.

Most pharmacies don't do what is called secondary billing (billing a primary and then a secondary insurance) because most software can't do it, and those that can are very complex. I assume from your question that they are capable of it and have tried...and failed. The vast majority of electronic pharmacy claims that are more than a few months old will not be paid by the insurance companies. So it is quite likely that the Pharmacy is being truthful when they say it is too late.

When the secondary insurance says that you 'have to do it through the pharmacy" they are either lying or don't know what they are talking about. Your secondary insurance is required by the summary plan description to reimburse those copays. If they will not allow the pharmacy to do it (which would be the easiest and quickest way for you to get your money), then they have to reimburse you directly when you submit the receipts and other documentation.

Call your secondary insurance again tomorrow. Ask to speak with either an ombudsman or patient advocate. They will of course have no clue what you are asking for, and will stonewall you for a while. Eventually they will get you to someone that can help you straighten things out.

Also contact your pharmacy and get your daughters receipt summary for the last year. It will show what medicines she got, how many, when, and what you paid. If your insurance is being a stickler and requires original receipts, the pharmacy can do that also.

Answer 2

I think you should read the paperwork that came with your plan. There must be a time limit within which you can file a claim.
Try going on the basis that it is your daughter's claim and she has "extra" time as she was a minor.
I'd also get myself a new pharmacy unless they're willing to fight for you.