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  1. #1

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    I need advise for coordination of benefits with Health Insurance

    Jurisdiction / State: California

    I have two Health Plans, my Primary is Healthnet through my work and the secondary is Cigna through my husband's work. For almost a year I have been submitting my receipts for RX to Cigna and they have been reimbursing my copay amount. In October my work changed our benefits and now my copay is a lot higher, from a couple dollars per RX to a min of $10 for RX. Now Cigna is stating there is no coordination of benefits for RX and they will not pay. It is my understanding that coordination of benefits is when the two companies work together to make sure the benefits are not being paid twice. If I am actually making the payment and submitting it for reimbursement, it does not fall under coordination of benefits, it's reimbursement?!? Is it right that just because I have two insurances one can just decide to waive all my RX benefits?

  2. #2
    Super Moderator Samaritan & Scholar

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    How and whether COB is managed depends entirely on the terms of the policies themselves. Just because you have two policies doesn't mean you are guaranteed full coverage of all bills.

  3. #3

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    Co-Ordination of benefits often has a priority of payor. Once the Carrier (Cigna) realized that you have your own policy with your employer (Health Net)- they become secondary payor. As an employee you own your own coverage through the group policy making this policy primary over all other coverages- as a dependent on a spouses plan - he is the primary owner of the policy makin his policy primary over any secondary policies he may obtain as a dependent on your plan. Through co-ordination of Benefits or COB -your CIGNA policy insurance can now reject certain claims until the group plan you are in with your employer (Primary) maximizes the benefit under the primary policy. It is not just for your protection that COB was developed, but also to protect individuals from using both insurance plans intermmitently at their own discretion.

  4. #4
    Super Moderator Samaritan & Scholar

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    You do realize that this post is more than two years old, right? And that the situation is likely long since resolved? Just sayin'.


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