Questions to Ask About Your Health Insurance
Horizons in Hemophilia, Spring 2007
By Michelle Fitzwater, Client Services Representative
Factor products can fall under several areas of coverage depending on your insurance plan. For many years these products fell into the major medical portion of your benefits, meaning they were subject to your deductible. Now, many plans list hemophilia products under the pharmacy benefit. Your costs may be a little less as you will pay a co-pay each time you order product (just as if you went to your local pharmacy to get a prescription filled). A new trend in the insurance industry is for drug card companies (or Pharmacy Benefit Managers) to develop or acquire their own specialty pharmacies.
Your employer decides which plan and which benefits within the plan to purchase for your company. They also determine the "plan design" which includes deductibles, coinsurance and/or co-payments as well as what is covered. Their choices will affect where your prescriptions will be covered and the limitations. Read the plan's list of exclusions and limitations.
What does all of this mean to you? It means that you may not have a choice in who provides your factor. So what can you do? You need to be an informed consumer. The following questions will help you evaluate your plan. You can download a full Health Care Plan Comparison Worksheet from our website. Click on the Pharmacy tab at www.hog.org.
Does your plan cover clotting factor? Where is coverage provided? Do you have a choice of providers?
Determine if factor is covered on your drug card or under the major medical plan. If you want to purchase factor from HoG, make sure HoG is a provider in the plan. Determine if there are limitations on coverage or if there is a specialty plan you will be required to use.
Does this plan include your primary care provider and your Hemophilia Treatment Center (HTC)?
Always try to find out this information before you sign up with a plan.
Does this plan have a lifetime limit or cap?
If so, will your expenditures for the next year put you over the top? If this is the case, then you may want to consider changing plans if there is another option. There are a few plans out there that also set limits on prescription drugs.
What are the plan's exclusions?
The policy may mention that it will cover "medically necessary" service, but exclude factor products.
What is the annual deductible? What are the out-of-pocket costs?
Determine your deductible, out-of-pocket maximums and co-payments. This amount can change each year. You may have a plan that requires a deductible for each family member, so be aware of that, too. You may end up paying double or triple the amount you first thought.
How much is the premium?
The premium is the amount that is paid for the insurance coverage. Your employer may pass some or all of this cost along to you. This amount can also change from year to year, so be on the look out.
Every pharmacy customer is important to HoG because you support research for a cure, nurse and social worker visits, activities and camp. The HoG staff is working hard to become an in-network provider for each health plan, but we need your help. You are a key component in this process by advocating for your choice in providers. If you find that there are going to be any changes with your insurance carrier, please notify Sherry Turner, Accounts Receivable Supervisor, or Michelle Fitzwater, Client Services Representative, at the HoG office.