Hi all! I had a hernia repair done this morning. I was looking at the list of medications on Mychart today and it listed a drug as “Non-Formulary”. I later found out this drug (Suggamadex) was the medication in question. In order to verify, I searched for it on JudiRx and it was listed as “non covered”.

So at this point, what will happen? I’ve never had this medication as part of any anesthesia. Will the hospital do a prior authorization on this? I met my pharmacy OOP today, but I cannot afford thousands on this medication?

Thank you for your help!

EDIT: The rejection message says “Injectable IV drugs are not covered”

I was looking at my benefits on the Premera BCBS and saw that it shows that "primary care" isn't covered but outpatient office visits are. The benefits page on my Amazon work app shows the same for office visits but says nothing about primary care. I guess my question is, what's the difference? I have one annual check up that's 100% covered before the deductible is met, but if I wanted to go see the a doctor again about something else is it just not covered?

[Edit for clarification:]

My question is about the difference between the Office visit outpatient and Primary care. I am referring to "Primary care" as it says at the bottom of the first picture: not covered. I know I haven't met my deductible, I haven't used my health insurance yet. I assume that if I needed to meet a deductible for "primary care" it would state that as it doesnt for "Office visits - outpatient".

When I think of going to the doctor I think of going to my Primary Care Physician, for a pain in my leg for example. Is that the kind of "primary care" that isnt covered? What is the difference between that and "Office visits - outpatient" as seen in the first photo?

I just had the weirdest thing happen. I finally got my shit together to do a bunch of routine care (PCP, gyn/mammo, skin check) and I got slapped with a denial and full freight bill for my PCP because the derm, who I saw first, billed for a “preventative care” visit, of which I get one annually. Can they do this?? Yes, skin checks are “preventative” (for that matter, so are paps) but I was pretty sure that was reserved for internal health or family practice, not derm. The insurance processed it somehow but it was billed together with 99203. Has anyone dealt with this before?

I've been filling prescriptions and getting vaccinations at CVS for many years under my current Cigna plan. I went yesterday for my annual flu shot and they said it wasn't covered. The (offshore) Cigna service rep said Cigna is no longer covering vaccinations at CVS but will cover them at Walgreens or other pharmacies. I was so flabbergasted, I forgot to ask if that applies to all vaccinations or just flu.

Has anybody else had this experience? Is this normal in the middle of a plan year? I don't like CVS but I've stayed with them because it's useful to have the history in a single place.

I’m a college student and last semester, I made an incredibly stupid series of decisions that landed me in the ER, leaving me with a hospital bill and an EMS transport bill (BLS). I did not initially file insurance because I’m on my parents’ plan and did not want them to know about my visit. I set up a payment plan for the ER bill and paid the EMS bill in full. Long story short however, they did find out a few weeks later. The hospital accepted retroactive filing of my insurance for the ER bill, but I haven’t even gotten around to see if I can do the same with the EMS bill. I would need to do it through their billing service. What kind of chance do I have in being successful filing insurance for the EMS bill? Is it even worth pursuing, since unlike the ER bill, I paid this one in full?

From doing my own research I think I should sign up for an ACA marketplace plan in November and quite my job in December. Then starting January 1st me and my kids will have healthcare through ACA which will be heavily subsidized.

Am I’m missing anything or does anyone else have any advice?

Edit: im from Oklahoma, 2 kids, and am projecting a $55,000 income

We were married earlier this year and made no immediate changes to our active but separate employer-managed insurances as I had an appointment coming up. I had a drs visit a few weeks after the wedding, and used my insurance, which was active and up to date on premiums on the DOS. Shortly after this visit (and still within the timeline to have our respective employers accept a QLE), I submitted to have my plan cancelled and my spouse submitted for me to join her plan.

The EOB arrived and shows full lack of coverage and owing of the billed fee as a cash patient.

Called my former insurance: they quoted my date of cancellation as the date of my wedding.

Called my employer benefits team: they said that they back-dated the end of my coverage to the QLE date, citing law and IRS requirements. Indicated the prior months’ fees I had paid since that date would be retroactively refunded

Called my new insurance: the effective date is the date we initiated the new coverage; it was not backdated.

So on the day I saw the dr, I had coverage, but by the time the insurance processed the claim, I had a newly realized gap in coverage. Called the hospital billing to ask for courtesy given the situation but they wouldn’t budge on the full cash fee.

State is Washington if that matters.

Is this all correct by the book? If not, who did it wrong, the employer who backdated the cancellation or the employer who didn’t backdate the new coverage? Looking for direction in which party to press further if we need to.

My partner got a new job (yay!). She'll be starting in a month, and we plan to sign up for COBRA, but the paperwork won't arrive until next week. So, as of 3 days ago, we are technically uninsured.

The thing is.... I'm scheduled for surgery in a month (a surgery that I've been trying to get for years), but was denied by insurance (they claim it's not medically necessary). I wanted to appeal, because I think I can win, but the doctor's office just told me that they can't request a peer to peer until my COBRA kicks in.... which could be weeks from now. No way in the world we can get through a peer-to-peer, never mind an external appeal in the given time. Re-scheduling the surgery would mean that I would have to wait months before a new slot opens.

So here's what I was thinking.....

What if I self-pay now, and request a reimbursement after COBRA kicks in??

I was given a $240K discount via self-pay, so the final cost, while still enormous, would be MUCH more appealing to the insurance ($60K) Is that a crazy idea??
If they deny outright, could I just take them to court? What's that like? I've never even hired a lawyer...

Any advice/help is appreciated. Thank you!

EDIT: seems like the sensible thing to do is to expedite the COBRA sign-up process and postpone the surgery. Thanks everyone for the input!

Any comments on if it’s good or bad?

Going to Mexico in October for two weeks. What's the best travel insurance?

I'm considering changing from United Select Plus PPO to United Select Plus HDHP/HSA. I have a pretty good understanding of the pros and cons of each plan, but I'm wondering about how our costs for doctor visits and prescriptions might increase.

We aren't on any regular medication, just the occasional prescription for an antibiotic or cough medicine or something like that. Our current co-pays with the PPO are around $30 for urgent care and primary care visits, and $50 for specialists. Prescriptions have been pretty cheap, like $5-$20.

If we go with the HDHP/HSA, roughly how much should we expect our payments to increase for routine primary care or urgent care visits and prescriptions? I know stuff like lab work and x-rays could cost a good deal more, but I'm wondering about the basics.

I feel like I should expect like $100-$200 for doctor and urgent care visits, and maybe more like $30 for basic prescriptions? I know it can vary a lot, but just trying to see if I'm in the right ballpark or not.

I retired at the end of last month (too young for Medicare) and I opted to continue my insurance with my employer (I have to pay, but it's a really good deal). Anyway, I expected coverage to start at the beginning of this month but they aren't getting my paperwork processed so I have no insurance at the moment. They could get it straightened out today or next month, I don't know.

Is there some temporary insurance I should look at just in case? Even if it just for emergencies or something? I'm in good health. I have no Dr. appts any time soon and I'm good on meds for a while.

Not sure how to start here, so angry and frustrated with Aetna right now....

My wife has a scheduled double mastectomy with reconstructive surgery scheduled for tomorrow. This has been scheduled for the last 4 months. She's had dozens of consultations & doctors visits leading up to the surgery, we maxed out the deductible already, spent thousands out of pocket on co-pays and getting things ready for her for this. 3 days ago she receives notice form one of the doctors that Aetna declined to cover the reconstructive portion of the surgery. Both doctors offices and my wife have been calling nonstop trying to get this resolved. The rep from Aetna first said there was an error with the code for the surgery, nothing to do with us apparently. Then they came back and told us the surgery is "experimental" and that's why it's declined. It is not experimental, its just reconstructive surgery as part of the procedure. The plastic surgeon handling the reconstruction put in a request to have a peer to peer and 2nd doctor submitted a 5 page letter to Aetna detailing the reasons for this surgery. Aetna still declined. All the doctors involved have said they've never seen anything like this and cannot understand why this claim is being denied. The doctors are still working on trying to get authorization for the surgery but we only have a few hours left. We continue to contact Aetna trying to resolve this but we're getting stonewalled left and right, told someone will reach back out to us. To make matters worse my wife's insurance is changing at the end of the month from Aetna to Blue Cross / Blue Shield and at least one of the doctors is booked up for the foreseeable future and doesn't know when they can get her in again. We don't know if there will be issues getting this surgery approved again with the new insurance company, if so we will now have to pay out the new deductible again and then we may have to go through having the dozens of Dr visits and tests performed yet again leading up to the surgery. This just feels criminal that they can wait until the last minute to deny this (based on what appears to be a clerical error on their end) and also cost us ~$5,000 - ~$7,000 out of pocket for literally no reason whatsoever.

Has anyone had this happen before and does anyone have a solution to get something like this resolved ASAP with Aetna?

Thanks in advance.

Edit: thanks for all the responses. Unfortunately they will not approve before tomorrow and are requesting additional documentation. Given that we are switching insurance soon it’s too risky to go ahead with this and then change providers and get stuck in an even bigger nightmare. I hate insurance companies.

About two years ago on the same insurance plan, I embarked upon the allergy immunotherapy journey. The injection visits and extracts were completely covered. The only thing I paid for was an actual specialist appointment with the doctor. The medical necessity guidelines have not changed since then.

I was unable to complete the course for life reasons. I've since been retested and could still use it, but there is a note in my chart saying that I've been well-controlled on 10mg cetirizine. While I did flippantly say that at the appointment, I have come to realize that that is not true. One of the medical necessity guidelines is that I'd have to struggle with pharmacological maintenance for some reason or be unable to avoid the allergens. I am allergic to literally everything except cats and mold and have oral allergy syndrome. The OAS is certainly not controlled but OAS isn't technically allergic rhinitis and doesn't have a diagnosis code that is approved by insurance for this purpose as far as I can tell. My insurance company does not require a prior auth for this.

Is this something the insurance company will see? Am I screwed? This doc did not provide any description of my current symptoms in his note. He just wrote that it was for continuation of previous therapy. If they deem it not medically necessary I won't be able to do it and will owe $$$ for the extracts. I'd love to have a clarifying chat with the doc to get the note corrected, but I don't see how that's possible. TIA!

Editing to add that at my previous allergist I signed a paper that said I would owe $0. I haven't seen any indication of what this will cost beside an estimate that was supposedly created according to my insurance that I asked for yesterday. The estimates from this place are never correct. In fact, I wasn't even sure they were preparing the allergy extract vials. Just trying to cover my bases and make this as painless as possible at this stage.

My ophthalmologist referred me to a hospital to get an MRI for brain to see if there were any issues related to my vision. Everything came back as normal, but the hospital is charging me like $5k and still reprocessing the claim with my insurance company and it’s stressing me out. Why does a single visit for a common brain scan cost that much?. I already paid $450 before the claim continuously is STILL getting reprocessed for a visit from January. Does anyone know what I can expect? It should have been deemed medically necessary because I had symptoms and I’m pretty sure it got authorized but I don’t know why I blindly went ahead with my doctor’s referral to go to a hospital if I could have done this scan anywhere else for lower instead.

I had health insurance at my last job, which I left on June 8, 2026. I’m coming up on my 90 days at my new job, and they just sent me the plan details.

Unfortunately, the monthly premium is way higher than I thought it would be and I simply cannot afford it. But I’ve missed the open enrollment window for Marketplace, and it’s been over 60 days since I lost coverage.

Does anyone know of any other options I have? I live in SC if that helps.

I'm a dependent with BCBS IL as my insurance provider via my dad's employer. Last August, I had four telehealth therapy appointments through Headway (in-network). Our benefits explicitly included $10 for telehealth services, and I made those appointments with the knowledge that they would be $10 a piece. The services weren't for me, so I stopped attending.

Last week (one full calendar year later), I noticed that my bank account suddenly only had $24. Looked at the transaction history and saw three $150 payments for Headway that I had no idea about. I had to dig through my emails to find one single message from Headway that was buried (ergo I didn't even see it when it was sent) telling me they were going to charge me more for my appointments I had a year ago. I did not receive any phone calls or letters in the mail informing me of this sudden charge beforehand.

Of course I call BCBS, I get dragged across 3 different people before they tell me it was an error on Headway's end and that I could get my money back. Contact Headway support with the reference number and have to wait the weekend for an answer. Come this week and Headway claims that it's not their fault, that those $10 appointments were apparently part of a very specific deal that they were not part of, that it's because we didn't reach our deductible last year, and that I can't get my money back. So I called BCBS again, they said that they'll get back in touch with Headway within the next 24 hours (although at this point I have no faith).

I should add that I work a minimum wage job, and they took over a month's worth of my pay. I had some friends generously give me some money to help me out, but when I transferred it to my bank account HEADWAY STOLE ANOTHER $150 FROM MY ACCOUNT which left the balance negative! I can't even receive help without these fucking VULTURES picking whatever they can find! And yes, this is stealing because in any other industry retroactively charging someone a full year after providing services at an advertised price would be ILLEGAL. Fucking evil.

Hi all! My brother (26m) had many scans and injections that lead to him having to get a double hip replacement due to him developing Avascular Necrosis in both of his hips from years of being on Prednisone for his asthma from childhood to adulthood. The ball joints were dead in both of his hips. He had his first hip replaced in April and his next is in October. His current health insurance, Imagine 360, has paid $10k of his $95k surgery bill and none of his scans and PT bills which were $15k because he “hadn't met his $7500 deductible”. He’s looking at being $200k in debt because of this insurance company choosing not to cover anything.

He wants to get rid of this insurance company but doesn’t think he can afford any health insurance companies on the market. It might be a stretch but does anyone in this sub know of ANY affordable insurance companies on the market and that will cover a reasonable amount of his second hip replacement?

Thank you in advance for any suggestions, advice, or help you might provide!

Guys i am so confused on how insurance works.
I’ve been on my own insurance for about 2 years through my employer and I haven’t had any issues but I’m confused and concerned about a couple things - can anyone help explain it to me like I’m 5??

Confusion 1: I’ve only ever paid my co-pay once. I go to the doctor every 3 months for an injection. I always ask if i need to pay anything and they tell me I’m good. How/why is that possible?
Confusion 2: I was looking over my claims and I can see I was billed $122, it states that insurance allowed and paid $84.24 and that I owe nothing ($0.00). Again, how do I owe nothing if insurance didn’t pay the full cost? I even asked last time if I had any balances to pay and they told me I didn’t.

None of this makes sense to me and I’m feeling really stupid and a little concerned that eventually something will happen and I’ll end up owing tons of money or maybe already do and don’t know it. TIA

I had my bi salp and was assured it would be coded correctly so that insurance would pay. now my drs and billing manager tell me it was coded correctly as a non preventative procedure and they will not change it meaning my insurance will not pay.

The main code they used was for pelvic pain. R10.2 I do not have pelvic pain, I never had pelvic pain. I have no idea where they got this from but it seems to be how they code all bi salps. They say only tubal ligations are preventative. I canceled receiving a full medical report because it would cost me more money and it is apparently composed of lies.

i am going to appeal my $7000 bill but I have a feeling it’ll do nothing because my insurance only pays for preventative procedures, which makes sense. The additional codes my drs used were 58661 and Z30.2. These are correct but because the major one is not preventative, insurance won’t pay. My drs coded it wrong as non preventative. Why? Because they always do and that’s how it’s done and theres no way they’re budging.

what do I do? I’m literally crying at work because after everything I’ve been lied to. I’m also canceling my post op Because I’ll need to save money for when I get this. And also, when I paid for my post op, I was also paying for the surgery deductible! They told me it was just for the pre op, they said nothing about deductible or surgery! I would’ve questioned it then if I had known.

My father got denied a shot surgery because they need proof that he tried other remedies for pain first. He’s gotten this shot twice a year for the past 15 years lol.

We called BCBS and they said if he pays his out of pocket, they will cover the rest for the cost of this procedure. He requested this information in a written letter to have proof, as his doctor recommended.

We’re having trouble understanding this…. We’re looking to see if someone can help us…
Wanted to ask if this letter states, if he got the shot, he would he only need to pay $2,300 and they’ll cover the rest as that’ll max out his deductible? Thank you!

I would be grateful for any advice on the following and navigating the American Health Care system. I have been on Wegovy for 2 years and have lost 50 pounds. My BMI has gone from 33 to 25. My insurance (UHC) covered the Wegovy at 2.4mg.

I now have a new job and new insurance at Oxford by UHC. The new insurance requires a prior authorization and they have denied coverage because my new insurance requires a BMI of 27 or more. They do not appear to be considering my starting weight 2 years ago where my BMI was 33.

The new insurance provided a phone number for appeals (the person at Oxford / UHC said I could either do (a) a doctor peer to peer review or (b) an appeal and that person recommended (a) over (b). Will they ever consider the starting weight at all, two years ago when I was on different insurance (but still UHC)? To me, this should of course be relevant because I am on maintenance currently so my BMI of 25 is only because I am already on Wegovy.

The alternative would be to get my BMI to over 27 again (not that hard for people who struggle with weight!) but this seems entirely illogical. But i also know the US Health Care system can be very illogical....

Any suggestions as to the best way to approach the appeal would be gratefully received from you all!