When it’s time to enroll in an annual health insurance plan—whether through your employer, Medicare, or Healthcare.gov—many of us default to staying with the same plan we had last year. But it may not be the same plan at all—coverage can change year-over-year. Some of the things that can change include:
Monthly payments for insurance coverage;
The doctors and hospitals in the plan’s network;
The medicines covered and the portion of the costs you pay at the pharmacy;
The deductible and out-of-pocket caps.
It can be very complicated and confusing to track the changes and find the information you need to make an informed decision. To help you navigate, here are some answers to questions you may have.
Q: I am taking prescription medicine, or a member of my family is. How do I find out in advance if a plan I am looking at covers that medicine?
A: Health plans keep lists of medicines that they cover; this list is called a formulary. Patients pay co-pays on medicines that are on their plan’s formulary when they pick up their medicines at the pharmacy. If a medicine is not on the formulary, the patient will pay more, up to the full cost of the drug.
Every health plan has a different list of medicines and co-pays for medicines, and the list may change during the year. Check the health plan’s website and if a formulary list is not there, you can call the plan to ask whether a specific medicine is covered. If a medicine isn’t covered by any of the plan options available to you, remember to check the manufacturer’s website to find out if you may be eligible for programs to help cover the cost of the medicines.
Q: What can I do if my plan doesn’t cover a prescribed medicine?
A: After you’ve enrolled, if you are prescribed a new treatment or medication that isn't covered or has a high co-pay, most plans have an appeals process that you can use to petition for affordable coverage of the treatment your doctor prescribed.
And when you’re prescribed a medicine, you can ask your doctor if there is a medical reason you should receive the branded medicine or whether a lower-cost generic substitution is available and acceptable.
Q: I am not taking a prescription medicine. What should I consider when choosing a healthcare plan?
A: Check what preventative care is available to you under the plan. Under the Affordable Care Act, healthcare plans are now required to provide many vital preventative screenings and wellness visits free of charge. Make full use of these opportunities to get healthy and stay healthy!
Q: What options do older Americans need to review on an annual basis?
A: It is important for people with Medicare to look at their plan options every year too, whether they get their insurance through a past employer or Medicare directly. There may be dozens of Medicare plans in your area, all with different costs and levels of coverage. Make sure you choose the best available plan to fit your changing needs.
Q: What support does Pfizer provide to people who have trouble paying for their medicines?
A: Through the PfizerRxPathways program, more than 40 Pfizer medicines are available completely free to eligible patients earning up to four times the Federal Poverty Level (annual income of $47,080 for a single person or $97,000 for a family of four). For people with or without health insurance who may not meet the income requirements for free medicines, Pfizer RxPathways offers a range of services including insurance counseling, co-pay help and discounts on Pfizer medicines.
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