Pharmacy benefit mismatch
The medication was Tier 1. The pharmacy charged like Tier 3.
The plan formulary placed the medication in a lower-cost tier. The pharmacy claim and receipt showed a higher copay than that tier allowed.
Expected copay$15
Charged at pharmacy$70
Difference$55
What happened
1
The formulary listed a lower tier
The plan data classified the medication as Tier 1 with a $15 expected copay.
2
The receipt showed a higher patient cost
The pharmacy receipt and claim showed the patient paid $70 for the same medication and fill date.
3
The tier mismatch was flagged
Insured Guard compared the claim against the formulary rule and surfaced the $55 difference.
A pharmacy copay should follow the formulary tier printed in the plan.
How do we know
It matches the medication to the benefit tier.
Insured Guard uses the medication identifier and plan formulary data to calculate the expected copay. If the claim or receipt shows a higher patient cost for the same drug and fill, the difference is flagged.