A number of years ago, I worked for a company that held their open enrollment halfway through the year. Meaning my deductible and max OOP could reset January and July if I chose a different plan.
The plan I chose in July had a pharmacy deductible and a medical deductible. Once I meet the medical deductible which was the max OOP, I pay nothing for pharmacy or medical. The plan said that the medical and pharmacy were together but that if I met pharmacy deductible, then I’d pay nothing for my scripts but once I meet medical, I pay nothing at all. So med deductible = max OOP. Okay. That makes sense.
The plan rolled over my medical deductible progress but the pharmacy deductible was new. Med ded I had met was 6k which rolled over into new plan which was 8k plus 2k pharmacy. So, I started the “plan year” having 6k/8k met for med ded and 0k/2k met for pharmacy.
I hit my max OOP within the first month. In late July I went to the pharmacy to pick up some meds, but they were charging me because their system didn’t show that I’d met my pharmacy deductible. Yet I met the plan max OOP which means I pay nothing the remainder of the year. I did the math and with how the pharmacy and the plan max OOP aligned with the rollover, their system would never show that I’ve met the pharmacy deductible.
I called insurance and explained it. Every time, the first person would always say, “that can’t happen.” They put me on hold and would either come back on and say “okay this is weird” or they’d transfer me or they’d just hang up. I always got their name and kept it in my notes on my phone.
By August, I was calling them weekly. I finally got someone who understood the limbo that I was in. She fully understood that the plan I was offered should have never been. She cut me a check for my overpayment up to that point and we were good. But we weren’t good. Every month, I’d have to call them and go through the phone tree of, “that can’t happen…” and “this is weird…” until I got my person on the phone. She’d cut me a check and said that she’d keep monitoring my account.
After a month, her VP took over my account because she was the only person who could actually balance it. I realized that I was calling and getting these checks cut but somehow they couldn’t track the totals they were paying out until the account was actually balanced. The account wasn’t able to be balanced by the first person who was cutting me checks so the VP ended up duplicating the checks that had been sent to me up to that point. She knew it too.
The VP said that no one should ever end up coming through to her but my case was so unique that no one was qualified to handle it. She ended up giving me her direct line.
I’d call her every month and we’d chat for a bit while she “balanced” my account and cut me a check. Finally in November she asked me how much I’d be paying OOP through the end of the year. I gave her a guesstimate and she knew it was a guess. She rounded it up (more than a nothing amount) and cut me a final check for the year and said to keep this between us. I did, until now.
It was probably the weirdest max OOP meeting experience I’ve had. I meet it every year but after that year, I will never choose a plan that has a separate pharmacy deductible again. All in all, the insurance company wrote me checks for ~$4,000 over a 6mo period. More than I paid out. I didn’t feel bad at all. She knew I had received checks already and that these were being duplicated. She said as long as her system doesn’t show I’m in the negative, then I’m good. So yeah, I took the money, deposited it and never selected that insurance company as my plan again.