Are some health and RX plans still exempt from annual or lifetime benefit caps?
I ask because a few days ago(I work in prescription processing), I received a call from a pharmacy about a member's copay, they were being charged the full amount for the prescription, the plan was paying none of it, even though the plan paid most of it(minus copay) up until this point. The message in the computer system said that "Maximum Benefit Exceeded", yes that's a direct quote. This usually means that for the remainder of the calendar year, the plan is not going to pay for any prescriptions.
Please note that this is NOT an individual plan, but a group plan for a well known(and large) group in my area. I inquired about this, but as a low rung help desk employee, I have limited access to policy decisions or documents, so I'm wondering if anyone has any definitive answers about this.
I also inquired as to whether this is an honest error in our system, that we or the plan failed to update the system to cancel the benefit limits. I informed my administrators about it as soon as possible, I'm kinda hoping it is this as the issue, then it can be fixed, and the member wouldn't be charged a huge sum of money per month, it was well above 100 dollars for the prescription without coverage from the plan.