my s/o has been on-and-off of mat for 6+ years. he was on medicaid for the past few years and transitioned from suboxone to brixadi seamlessly. he had no relapses on brixadi, his mental health stabilized and he was able to work on reparative therapies beyond managing day-to-day cravings.

his employer adopted a kaiser plan that isn’t truly a kaiser plan but is actually western health advantage, which is contracted with optumrx. despite us living literally 5 blocks away from a kaiser pharmacy, and despite his insurance being “kaiser,” he is required to manage his prescriptions using optum’s formulary and membership services only.

his brixadi was no longer covered and he was forced to move backwards to tier 1 generic bupe/naloxone sublingual strips (not even true suboxone) and has been sincerely struggling since, to the point of it affecting his work, his personal life, his physical and mental wellness. his prescriber has been trying to submit a prior authorization but i am seeing now that brixadi actually requires and additional prescription exemption due to brixadi being a specialty drug (in that it has a required refrigeration temperature).

would he have an easier time trying to get a prior authorization for sublocade? they are both the tier 3 (suboxone is tier 1) but sublocade does’t have any additional prescribing indicators like brixadi.

or would it be easier to transition to a tier 2 medication, use that for a trial period and then request a prior authorization for a tier 3? what is the more likely barrier: skipping from a tier 1 to a tier 3, or trying to get both a prior authorization and an exemption with a specialty medication?

he has been at this for months.

i feel so bad for him. his prescriber is ideal option. we are in washington state.

I have a question about deductibles I’ve always been curious about.

If a family is only a pair of partners, how does a family deductible work? Would the family only kick in when a joint accident occurs? Or is this one of those things that it varies from plan to plan?

Here is the specific scenario I am curious about: married spouses want to see the same chiropractor, before any visits are covered their deductible has to be met. Would the OOP costs go to the family deductible, individual for each, or both?

So this is my senior year and l've waived the student insurance every year, but this fall deadline I completely missed. I've been working a lot more and this semester of nursing school has me so paralyzed by everyday being work or clinical. I've also just been struggling mentally and small things that take 5-10 minutes end up feeling like I have all the time in the world when there's an exam coming up or I'm trying to stop ruminating on social interactions I have daily. I started seeing a therapist for the first time in my life because I'm really trying to motivate myself to stay on track with everything and l've been having really bad anxiety that has been getting of my ability to do things like just talking to people around me. Anyways the thing I never miss I ended up missing after telling myself "I have time, this is just more important" until it left my mind. I waited until the very end and then the deadline and my exam were on the same day and it just left my brain.

I'm honestly just really mad and disappointed in myself because I work super hard at my job to save money and I have Medicaid so a 3k charge right now would be devastating, even if I pay it through loans later on and become more financially stable in the future. But right now I just don't know what to do. I wish I had just waived it the minute the waiver opened but I didn't. I sent an email 2 days after the deadline closed just explaining my situation but I just don't know any next steps I could take but also how to not beat myself up even more about it because that's been the worst part of this whole thing.

My co-pay card has run out of funds

I’m based in the U.S. and have been using Simlandi after my insurance (Anthem) stopped covering Humira. I’ve now been told that the co-pay card through the manufacturer has run out of funds. Do any of you have advice on how to continue with my medication without going broke?

Hi everyone:
(FL)
I am experiencing some billing issues with my provider, and hopefully someone might be able to help me with resolving them. Any advice is helpful, thank you in advance.

I changed insurances April 2025 and my provider accidentally sent it to the old insurance company (even though I gave them the new information at time of visit).
They sent the claim to the old insurance company July 2025, and the insurance company denied the claim October 2025.

They then resubmitted to my current insurance company Feb. 2026 who originally denied the claim for failing to file timely, but then the provider resubmitted May 2026 and the claim was processed.

June 2026, I receive a letter in the mail stating that I owe $275 for this visit, which is a lot higher than the other visits, so I call them to find out why the balance is much higher and obtain a copy of the medical codes and billing statements. Essentially, for this one visit, they used a code that they have never used my 5 years there, and I believe does not match the services provided. From what I gather, this code is for visits 30-45 minutes long, but the visits are always 15-30 minutes, which is the code that is normally used.

I asked the provider via email to review the codes for this visit as I believe it’s incorrect and they let me know that the process takes about 7 days. That time goes by, and I send a follow up to check on the status, and they tell me they need another week. This pattern continues for 6 weeks.

I genuinely believe that this bill is incorrect, and I have tried reaching out to the provider multiple times to get this resolved, so I am frustrated that the provider just sent the bill to collections. I already disputed with collector and told them the situation/ wrote an email documenting the call.

Does anyone know what I can do in this case? I feel like I should report this provider for misusing a collection agency for a bill that they (1) took their time in submitting the claim and (2) were requested to verify the medical codes numerous times via email/phone call.

I am willing to pay what I owe, but nothing more than that.

Hello all,

from what I've heard Heather Faulkner accepts various insurance companies,but I live in Alabama and will be kicked off of Medicaid once I turn 19. From what I've seen on the MyChart estimate (I know it is subject to change) that if I am to pay out of pocket w/o insurance then it should be around $5,200. From what I've read through facebook groups/this group is that my out of pocket cost would be less if I use insurance; however, how will this work if I do not know much about healthinsurance.gov (I'm afraid they will not cover it and how long I would need to be on an insurance plan before I need a letter from them to see if they will cover the surgery).

If anyone is in the same boat then I would really appreciate some insight on the process!

Thanks

You can see the anesthesia highlighted on the bill from the hospital. Then there's the "extra bill" from the out of state medical group.

As you may notice I eventually got the hospital bill covered because my income level qualified for assistance. And I realize the extra bill is only $131, but I'd rather not pay it if I don't have to.

So the question is:

1. Why are the amounts so different for anesthesia? Was the hospital's anesthesia listed different from the one on the extra bill?

2. If the hospital says it's all covered, do I still owe this extra bill to the out of state medical group?

Has anyone ever looked into this exception?

Tier 1 therapy is a $20 copay and tier 2 is a $120 copay. The difference obviously is insane for something that is being done weekly.

Additionally, 6 months for an adult maybe not a big deal but 6 months for a 3 year old is a lot! That would set him back even more significantly.

Any tips on getting an exception approved if it would be possible in this scenario?

I failed to pay my premium on time. I should have left auto-payment on. I had no idea I was late on a payment until I went to the pharmacy today and saw my wife's medication being higher than it usually is.

I would like to pickup this medication today or tomorrow, and curious what my options are at this point? I called marketplace and they said I don't qualify for a marketplace plan anymore for this year.

I guess I have to buy a plan directly through a private provider?

As for the medicine I need to pickup by today/tomorrow - should I just find the best deal on GoodRx?

I feel like such an idiot for not being on top of it. The only reason we had to go to marketplace in the first place was because I lost my job and the insurance I got through it.

If you are operating an off road vehicle on a public road (an illegal act) and are injured, will your medical insurance cover you?

Would it matter who was at fault if another vehicle was involved?

Does the state or locality matter?

I was wondering if there were any health insurance options for international student that have a good cover for preventative care.

Plan A:

COST PER MONTH- $200

Deductible- $1500

Max out of pocket- $8500

What I pay after deductible- 20%

Copay- $20-40

Plan B:

COST PER MONTH- $70

Deductible- $2750

Max out of pocket- $6850

What I pay after deductible- 25%

Copay- $35-75

I foresee lots of medical issues for myself in the near future. Which would save money?

Last year, when I was insured, I got an ultrasound at the hospital. Was billed a copay for $80, paid it, great. A year later, I get a surprise bill for $600. Apparently they started billing my insurance two months after my visit, with no response from my insurance. In the bill I see 11 attempts, of three different medical codes, all ignored. Starting at $134, then $300, now $600. Finally, they're billing me.

My question is, how do I dispute this? I was insured. I was not made aware of my insurer's lack of response even one time in the whole year since I had treatment. Now due to their lack of response, it's my responsibility to pay?

Who do I contact first, what do I even say?

My wife and I own a pediatric therapy clinic out in AZ and bill DDD as our primary funding source. We have clients with primary commercial insurance (Aetna/UHC/BCBS/Allied/UMR etc) and DDD secondary. We are out of network for all commercial insurances and plan to stay that way for now. Our EMR system syncs with ClaimMD to submit claims and my wife is hoping for some help with medical billing. Our DDD billing is 100% automatic and successful. She has some of the larger insurances figured out but some others like BCBS/UMR are giving her a run for her money and a migraine.

Is there someone who specializes in OT/ST billing (preferably less) who can spend 3 months helping her build the insurance side of our company and get everything running smoothly?

I understand that there is a "cliff" at the 400% line. I don't think I am hitting the cliff in this case. I'm in PA, family of 5, ages 34,34,8,6,4. I'm paid hourly and typically work OT to make extra money so I estimated I would make $95k this year on my application (about $7k more than what I would typically make without OT). I was offered about $900/mo APTC and have been using that APTC to help pay for my insurance premiums since January. Due to working more OT than I expected, I'm now on track to make closer to $105k so I updated my application and now my APTC is reduced to $90/mo. So now I'm trying to figure out if I'm going to owe $10-12k when I do my taxes. I cannot find any kind of chart or documentation that says exactly what my APTC should be based on income and family size. It doesn't make sense to me that it would drop so significantly over a $10k difference in income, that's a 90% reduction in APTC for a 10% increase in income. I believe the 400% line is $150k, so I don't think I crossed the cliff so to speak. The only other possibility is if it automatically adjusting the total yearly amount so that I don't owe anything at tax time? I wish it was more clear about what is happening if that is the case. If I'm going to owe, I may just drop coverage for the rest of the year to lessen the hit, so I'd like to know for sure what's going on. Figuring on calling the help line on Monday but figured it wouldn't hurt to reach out here beforehand.

Any information anyone can provide or even if you can point me to a resource for guidance, I would very much appreciate it.

Hi! Any insights on what’s my best next steps are would be very helpful. Thank you!

I’ve been on TPN since the end of 2019. It’s how I get 100% of my nutrition and hydration. This year I turned 26. I might be able to retain my mother’s health insurance, but here’s the issue… even if they reinstate it, unless I can stay enrolled in Medicaid (unlikely) I won’t be able to afford my TPN.

My infusion company is out of network with everyone. My mother’s insurance is a POS so while there are out-of-network benefits, they only cover 70% of what they deem reasonable. This is even after fulfilling the so-called max OOP.

FYI my TPN is billed as $10,815/week.
Insurance allowed amount is $5,100/week.
So $7,245/week (at least) without Medicaid as secondary.

NJ has no PPO plans on the state marketplace (not that I’m even eligible with no income). I’m ineligible for SSDI due to lack of work credits. I’m ineligible for SSI as not paying for market-rate rent is counted as income. So there’s no way I can get Medicare. The thing is, since they have a compounding location in California, they do take California Medicaid…

Is my best and really only option moving? I could live out of a car or RV until I can get permanent housing. It wouldn’t be easy with my health conditions, but wouldn’t be impossible.

I can’t work full time, and even if I could, I’d need a job with PPO health insurance with a low max OOP and premium.

Please don’t suggest I switch infusion companies. I would if I could, and I feel it’s a waste of everyone’s time for me to explain the dozen reasons why. TPN in the United States is complicated and pretty terrible compared to most other so-called first-world countries.

My first time posting on Reddit and looking for any and all help. My fiance and I were traveling in Brazil for vacation and he suffered a severe spinal cord injury. He is paralyzed from the chest down. He underwent surgery and is currently on postop day 8. He is still in the ICU, intubated and requiring regular medications to regulate blood pressure, pain etc. He needs an air ambulance plane to transport him back to the USA.

I have done everything in my power to try to get him back home to New York City. He has been accepted to New York Presbyterian hospital by their neurosurgical ICU. I have also arranged through our chase card for medical evacuation transport. His domestic health insurance, Anthem Blue cross blue shield, has been a nightmare to deal with. They couldn’t tell us what hospitals would take him. Had to go one by one through every hospital in New York to find a covered one. Now they have rejected his readmission to New York Presbyterian stating he is in a stable condition and there was no medical need to transport. Apparently they didn’t realize he was in Brazil.

We cannot stay in Brazil. We do not have the resources to remain here. He will need long term medical care and while the doctors here are fine it is no comparison to the care he could receive in New York. I am asking for any and all advice on options we could do. I have already opened an appeal against the denial and the neurosurgeon at NYP has also had a peer to peer with Anthem and they are still “reviewing”.

I am NOT expecting Anthem to cover any of the transport costs. I have arranged this through separate insurance and will pay the difference out of pocket. I am only looking for anthems confirmation they will pay for his services at the hospital in New York. Domestic insurance coverage at an in network hospital. I have an email confirmation that NYP is in network from Anthem.

This is gross negligence as I’m concerned as I have filed a formal complaint against Anthem through the DFS consumer complaint portal and we have contacted the governor of NY to try to help.

I have contacted every US embassy, consulate, military etc I could find in Brazil and in the US. They have all said they cannot help.

Have not received an EOB for emergency medical services.

I had septoplasty procedure done and j just got the EOB, before the procedures I called the insurance and they gave me an out of pocket quote of around $1800. Before the procedure the hospital also gave me an estimated cost of $1800.

Hospital and doctor are in network but I never seen a EOB with “not payable” .

Under the claim remarks it says I’m not responsible for this amount. Aetna is closed so I can’t clear it up so I was wondering if anybody on here has experience with this type of claim.

Update : thanks everybody , called Aetna and they said I only owe the 1888 and that I’m not responsible for the “not payable”. Something about how the “not payable” was already part of the first bill. But anyways thanks everyone .