COVERAGE - What services and medications will I have access to under my plan?
COVERAGE – What services and medications will I have access to under my plan?
There are several different ways to define “Coverage” when you’re referring to the details of an insurance plan, but this section will focus on the specific procedures, treatments, and prescriptions that your health insurance plan will approve. Basically, if you have a problem and you sign up for an insurance plan, you want to make sure that specific problem is something that falls under the benefits outlined in your plan.
The majority of what is required to be covered by insurances is either mandated by the Affordable Cart Act or derived from basic Medicare standards, so most of coverage details for medical services are the same across the major commercial insurers. But, that doesn’t mean they are all the same, either. Standard medical services like doctor’s visits, generic medications, and vaccines, will be accepted on almost any plan. However, if you are planning to do non-standard things, like cosmetic surgeries, treatment for rare or complex diagnoses, or special blood testing, you should really try to dig a little deeper into the plan to see what types of services are actually covered.
Essentially, the best way to think about how to get the “best” coverage you need is to start by seeking coverage for your most expensive service. Call your providers and ask for a price quote for certain types of visits you expect to incur during the benefit year. You will probably never get a definite answer (for a variety of really good reasons that we’ll answer in another post), but you should be able to get a ballpark idea what kind of prices you can expect. Ask for the specific CPT Codes that will be used for your procedures so you can tell your insurer exactly what you want to verify. Then, figure out which insurance plan covers the services that would cost the most if you didn’t have coverage because they will make the biggest difference in your bottom line for out-of-pocket expenses.
Here is a simplified chart that helps you visualize the types of priorities you should be making when selecting coverage. These are just working estimates and are by no means exact, especially considering that we just spent 1,000 words earlier in this article talking about how the “Cost If Covered” part of the equation could vary drastically depending on your plan. The point is to get a sense of the risk involved in having, or not having, coverage for a particular service.
Obviously, having coverage for the ER visits would be Priority #1 in this scenario. A single accident with no coverage could be financially devastating. But, those are generally few and far between for most people. Again, this goes back to the concept of placing a bet on your health expenses. You should go down the list of your expected health costs and find a plan that will pay for all of your highest priced items first, since they will have the biggest net difference on your potential bottom line.
After all, what would be worse? Having to pay an extra $75 because a PCP visit was denied, or having to pay an extra $45,000 because your hospital visit was denied? A PCP visit is more likely to occur, but the one time the hospital visit gets denied will potentially be the most devastating. However, because denials are still not too common if you have insurance, the most common factor that comes up when differentiating plans based on their overall coverage relates to prescriptions, as they can vary greatly depending on the plan.
Prescription Coverage Details
One plan could offer a certain drug at a $10 copay, while another plan might not cover it at all and either cost you $200 out-of-pocket or force you to switch to a different medication that your insurance prefers. Neither option is ideal, as you’re ultimately either poorer or sicker if your medication isn’t covered by your insurance. The insurers structure their drug coverage decisions based on the population of their insured, so finding the plan that best suits your patient profile could make a big difference in prescription costs.
So, how do you find out which drugs are covered on which plan?
To be confident in your choice, you should learn the details of the prospective plan’s drug formulary. Most of the time, a simple Google search with “Name of Insurance Plan, Drug Formulary List” in the search box will direct you to a PDF of the plan’s details. If not, there should a link on the insurance provider’s website or a phone number you can call to request a copy by mail or email. Prescriptions are one of the few health expenses you can make an accurate budget for up front, so it is important to know how your plan will cover the medications you are currently taking.
If you think your medication may be too expensive, even with commercial insurance, there may be programs that you can sign up for to reduce the cost. Please contact our office to discuss potential coupons, savings programs, and rebates that may be available for your medication. There are a lot of programs available to receive discounted prices on your medications, so it is ultimately in your best interest to take advantage of them when you can. If you are a current patient, ask for details!