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Self-funded ppo meds coverage
Jan 23, 2013

Hi, I am getting ready to get my results back,( which I'm sure will be positive) and I am trying to figure out my coverage for me and my wife. My company uses a TPA. To handle all claim's and payment. The TPA has a drug formulary that has over 25 different medications specifically for HIV/AIDS, but when I use they're "price and save" Internet tool to lookup what my plan covers, it tells me, " claim $ exceeded". My summary of benefits says there is no amnual limit on prescriptions! Is there a secret limit they put on certain medications? What are my rights as far as a self-funded ppo plan member. Thanks!!

Response from Mr. Chambers

If you have a true Summary Plan Description (SPD) as required by federal law (ERISA), it should have all limits as well as complete description of benefits.

Many employers use an abbreviated plan summary even though the law requires a complete SPD, although I doubt they would intentionally hide a maximum benefit.

I suggest you call the TPA, tell them you are having problems with their online "price and save" program. Tell them what the message states and ask if there is a maximum limit you haven't found or if the program has some kind of a glitch.

Hopefully, you won't have to go into detail about your specific medications in this phone call, however, it really makes no difference, as almost all employers large enough to use self funding also know the legal problems they can have by knowing too much about their employees' medical conditions. To prevent these problems, they set up very specific walls that allows the employer to get general information about claims but nothing that specifically identifies who and what the claims are for.

Good luck, Jacques

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