Choosing the right plan

Every health plan is different. It’s important to research your options before you make a purchase. Here are a few things to do:

Be sure to review the type of plan it is

A health maintenance organization (HMO), preferred provider organization (PPO), point-of-service plan (POS), and high-deductible health plan, all have pros and cons.

Check out the in-network providers

Make sure the doctors, labs, facilities, pharmacies, specialty pharmacies, and mail-order coverage meet your needs. See if other options can save you money.

Examine cost-sharing rates and limits

Care, pharmacy, copayments, coinsurance, and maximum out-of-pocket all add up. Look at the details of your plan carefully so you can budget accordingly.

Look at the formulary

A formulary is the list of prescription drugs covered by an insurance plan. Ask your doctor about various treatment options and be open about your concerns. If you know your medication options, you can see whether it’s covered and how much it costs.

Know what isn’t covered

Sometimes, a healthcare provider will order a treatment that isn’t covered by your health plan. If you know what to expect, trying to get coverage may be less stressful.

When your treatment isn’t covered

Negotiating with an insurance company can be a process. If your plan doesn’t cover the treatment you need, you may have to submit an exception to the formulary and ask for coverage.

Here are a few things you’ll want to do if you’re working with your insurance company:

Keep detailed records

When you’re making an appeal or negotiating with an insurance company, write everything down. Keep track of the date and time, who you talked to, and what they said. If you receive a call-reference number, write it down. And keep a copy of every form, statement, and medical record you have. It’s good to be prepared.

Be patient and persistent

It may take months to get coverage. Some people need to call their insurance company every day. It’s important to stay calm and keep your composure. If someone cannot help you, ask for their supervisor.

Be clear

People who work for insurance companies don’t always have medical degrees. If you know your plan’s policies and can explain the issue, it’s easier for the person on the other end of the line to help. You may also have the option to let your doctor’s office call to speak with other doctors at the insurance agency.

Make a paper trail

If you get an approval over the phone, make sure you get it in writing. Request a mailed or emailed copy of any important information discussed over the phone. Be sure to certify any important papers you send with a receipt, so there’s no discrepancy as to whether or not the paperwork was received.