Help Insurance Question!


New member
I am in open season for my insurance and thinking about switching plans because of cost.

Here is my question: The plan has an out of pocket max of $5000.00. However the plan brocure states copays for specialty drugs not filled through the plan specialty pharmacy do not count towards the out of pocket max. Cayston is only available through 5 pharmacies, all of which are not my plan's. Since it is not offered by my plan and I am forced to go out of network, would the copay count towards the Out of Pocket?

Lena Bean

New member
Doesn't sound like it would. Also, the out of pocket max usually only applies towards medical as in doctors/hospitals/things that involve "providers" and not prescriptions. Hope that helped a little.


Super Moderator
Hi LeChampion, I went through something similar last January when we switched to a high deductible health plan. Our deductible is $3,300 and out of pocket max is $6,600. Just as with your plan, prescriptions count toward the deductible/out of pocket max. The plan (United Healthcare) dictated that I filled specialty drugs through their pharmacy or they would not pay for it at all. Because Cayston could not be filled at their pharmacy they gave me an override to fill it w/ CF Services Pharmacy. CF Services handled all the "dirty work" for me and worked it out with the insurance company. I also ended up having to get an override fill Pulmozyme through CF Services because the specialty pharmacy they were trying to make me use could not bill Medicare as my secondary. To be honest, it was a huge pain in the butt and lots of phone calls but it did get worked out. These copays were all put toward our out of pocket max.

I think with the Cayston you could almost certainly get an override because you are not making a choice not to fill it through their specialty pharmacy, their pharmacy CAN'T fill it, so you have no choice but to go out of network. I think there would be a little red tape to clear, but in the end I think you could get it squared away and it would count toward your out of pocket max.

What pharmacy are you using to fill Cayston now? I think both CF Services and Foundation Care would advocate for you on this. In my opinion, it would be really ridiculous if this couldn't be worked out.

Off topic but do you get any assistance with prescription costs through the Cystic Fibrosis Patient Assistance Foundation or any copay card programs? I only ask because I was SUPER afraid of going on the high deductible plan but in the end I actually SAVED money because the assistance program picks up the huge copays of Cayston and Pulmozyme and that $ went toward my deductible. So it actually really helped me meet our deductible/out of pocket max.

Anyway, hope this helps at all. Let me know if you have any other questions that I could try to answer!

Take care,

Autumn 32 w/CF


New member
You need to talk to your hr person, they should be able to ind ou specifically how it woul pay.

I am in hr and my hdhp worked like autumns but there is no guarantee, so find out for sure!


New member
Thank you all..l.I did not think about the option of override. I will call them and ask. Spoke with them today, and the answer was no that the co-pay for Cayston would not count towards my OOPM.


New member
FYI in case anyone wants to know and this saved us alot of money in copays and max out of pockets. We only pay for health ins. only and do not pay any copays or copays for meds or anything. The way we did this is I put my daughter on my health ins. and then on her dads as a secondary ins. that way we pay for him on each of our insurances but since the secondary picks up everything the primary insurance doesnt pay then we dont pay anything out of pocket. So this will only work if both you and the childs father works and has insurance. Put the child on both policies. Now you do need to weigh in the factor of how much it is costing you extra on each policy for the child to be on there versus paying all the copays and med. copays. But in our insurance it is cheaper this way than in the long run of anything out of pocket!! And no surprise hospital bills jumping at you when you dont have the money or the money for expensive meds. Also make sure you remember if your child is 26 or under and have their own ins. thru where they work and if you can afford to help them out by putting them on your health insurance also it will be considered secondary and do the same thing. My son is 22 and we put him on our ins. and he has no copays and pays for no medicines at all due to this. We might not be able to help him out financially but this helps him alot!!!!