How do I know what my plan covers?
Coverage for prescription drugs, doctor's office visits and other
medical expenses vary widely among different healthcare insurance
plans. In order for you and your provider to be reimbursed for
the medicines, treatments, and services provided, it is important
that you understand the coverage and benefits of your health plan.
Most health plans will provide you with a policy handbook detailing
the benefits of your plan. If you have any questions regarding
your coverage after reviewing the policy handbook, you should
contact your health insurance plan's member services department.
Most insurance companies offer a toll free customer service number
that you can call with specific questions about your health plan.
(This number is typically found on the back of your insurance
card.) The insurance plan representative should be able to explain
your insurance coverage for any of the products or services that
you receive.
When calling your insurance company about your health insurance
benefits and coverage, you may want to ask these questions:
- Does this policy cover the product or service that I am
to receive?
- Are there any restrictions to obtaining coverage (i.e.,
Do I have to go to a particular physician? Must I get the service
approved first by my health insurance company? Is coverage of
this treatment limited to a particular diagnosis?)
- Are there any benefit
limitations to this coverage? Is there a dollar limit? Is
there a lifetime
maximum benefit?
- Do I have a copayment
or coinsurance?
- Do I have a deductible?
Most plans require that a treatment be considered "medically
necessary" for your health condition before considering coverage
of it. Medically necessary is a term used by insurance companies
to describe care that is appropriate according to generally accepted
standards of medical practice. In other words, the insurance company
agrees that the medical treatment is needed for the condition.
Many insurance companies cover all drugs that are approved by
the Food and Drug Administration (FDA), while other insurance
companies use a formulary.
A formulary is a list of approved drugs under a health plan's
prescription drug benefit. If the drug is not on the formulary,
then the insurance company may not cover it at all or it may only
be partially covered. If a drug is not on the formulary, you will
likely have to pay a co-payment.
How do I use my medical benefits?
Medical benefits vary from plan to plan, and different plans
under the same insurance company can offer different benefits.
Services included under medical benefits can include coverage
of medical expenses such as provider visits at the hospital, office,
or home. In addition, hospital services such as daily room and
board charges; routine nursing care; hospital expenses, such as
x-rays, anesthesia, medicine, and operating room; and other services
relating to medical care and treatment of patient while in the
hospital are usually covered under medical benefits. Coverage
for services as a result of catastrophic accidents or prolonged
illnesses can also be included in the medical benefit.
In some cases, prescription drug coverage is bundled under the
medical benefits and not covered separately as a pharmaceutical
benefit.
To determine what is covered under your medical benefits, contact
the insurance company directly or refer to your manual if one
was provided.
The insurance company that administers your medical benefits
will provide you with an insurance card. You will present this
card to the medical facility that is delivering the medical service.
You may be required to pay a copayment or coinsurance based on
the contracted benefits provided to you by the insurance company.
Depending on the type of plan (HMO, PPO, etc.) you may be required
to seek medical services at specific hospitals or physician offices.
Please be sure to review your handbook or contact your plan directly
to identify any restrictions you may have or to obtain a list
of participating health care providers.
How do I use my prescription benefits?
In many cases, an insurance plan has another company known as
a Pharmacy Benefit Manager (PBM)
that manages prescription drug benefits and handles calls about
prescription coverage. Therefore, you may have to call another
phone number for your specific prescription drug benefit information.
Your prescription drug benefits will vary. Some health plans
issue a separate prescription drug card to members. You present
this prescription drug card at the pharmacy when you have your
prescription filled and you may be required to pay a copayment.
Often, by using your insurance information, the pharmacy electronically
submits the claim to your insurance company. The electronic claim
is processed and paid without you having to complete additional
paperwork.
Many health plans also provide a mail order prescription benefit.
Mail order benefits work well for people taking maintenance medications.
Usually your health plan will require you to complete a specific
form or contact them by phone to begin this service. By utilizing
mail order services, members can typically get a larger supply
of medication (some plans allow a 90-day supply versus a 30-day
supply). Some medications are only available through specialty
pharmacies. These pharmacies handle medications that have special
requirements or handling needs. The specialty pharmacy will ship
your prescriptions directly to you or your provider. Various specialty
pharmacies are able to assist patients with reimbursement issues
when insurance difficulties arise with access to certain treatments.
If you have insurance related problems accessing a treatment prescribed
for pulmonary hypertension that is required to be accessed through
a specialty pharmacy, contact your specialty pharmacy to see what
assistance they can provide.
Many insurance plans have set up a network of pharmacies that
can provide pharmacy services to their beneficiaries. Your pharmacy
benefit may be set up so that you pay a lower amount for prescriptions
when you go to a pharmacy within that network, often referred
to as an "in-network" pharmacy. In some cases, going to an out-of-network
pharmacy may mean you will pay more or that your prescription
may not be covered by your insurance plan at all.
If you are unsure whether or not your health plan has a network,
ask someone in your employer's human resources department or call
the insurance company. If there is a network, they can provide
you with a list of in-network pharmacies. Be sure to obtain the
most current list available. Often you can request a list of network
pharmacies by calling the customer service phone number on your
insurance or prescription drug card.
Some insurance companies require that you pay for your prescriptions
up front, out of your own money, and then file a claim for reimbursement.
This resource was developed in 2004. Some of the content may be out of date or no longer relevant. PHA is working to update and re-organize this guide. We apologize for any inconvenience.
