In the first installment of Demystifying Health Insurance, we covered how to determine the total cost of a health plan. As a reminder, the answer is: Premiums + Deductibles + Cost Share = Total Cost. Now that you are all math whizzes and are getting bored with Sudoku, it’s time to move up to word problems!
If Sally has diabetes and is riding on a train moving at 60 mph, what health plan should she select to ensure her blood sugar is stable when the train gets to the station 200 miles away? Your guess is as good as hers, but I recommend starting with Total Cost + 3 Ds.
The 3 Ds in selecting a health plan:
- Are my Doctors covered?
- Are my Drugs covered?
- Are my Devices covered?
The lowest cost plan might not be right for you if you have to change one or more of these Ds. There are two places to look to determine coverage inclusion – the plan Network (doctors and some devices) and the plan Formulary (drugs and some devices). The health plan you are considering should have a website link that will lead you to both lists.
The network (such as Anthem, Blue Cross/Blue Shield, CIGNA, United Healthcare, etc.) should offer a list of covered doctors, hospitals, and other healthcare facilities. Go to the link and look up your providers. If they are missing, call your provider to see if they accept that network. If not, you need to decide if you like your doctor’s bedside manner enough to pay more to continue in their care or if you want to select a different plan.
Make sure you factor in any extra cost when arriving at your total cost. If your doctor is out of network, then you may be subject to an additional deductible amount, higher co-share percentage, and/or a higher out-of-pocket maximum. Places to ask about coverage and extra costs are your Human Resources or Benefits Department if you’re covered by your employer, or your insurance company or broker if you are buying coverage on your own.
The health plan’s website should also provide a link to the plan formulary. This is the list of drugs covered under the plan. Formularies are managed by pharmacy benefit managers (PBMs) – such as Express Scripts, CVS Caremark, Optum Rx, etc. – and they determine your access to and cost of the drugs you need to manage your diabetes.
Key questions to consider:
- Is my drug covered?
- If so, what is the copay level for the drug?
- Is the drug covered pre-deductible (meaning I only pay the copay) or do I have to meet the deductible first before the copay level starts?
- Do I need a prior authorization to get my drug? If you are switching plans or PBMs, it is possible they will require one before approving your prescription, even if you’ve been on it for years. If so, get this in motion ASAP as it can take time. Some plans make you jump through this hoop annually so prepare the documentation in advance, but not too far in advance as they may want the date to be in the new plan year. (Yes, this is frustrating, horrible, and unfair, but often a reality that must be addressed to get the medications you need).
If your drug is not covered under the plan, find out what alternative drugs in the same or similar class are available and check with your doctor (assuming they are in the network 😊) to see if it is reasonable for you to switch. (It’s not reasonable and it’s enraging to make you switch, but it’s also a reality you need to be prepared for).
Devices and related supplies may be covered under the plan network or the formulary depending upon the plan, so you need to look at both lists before panicking. As a general rule of thumb, devices that last for many years, like a tubed insulin pump, are typically covered under the network side of the plan (also called major medical). Often, but not always, the supplies for these devices are also covered under the network mechanisms of a plan versus at the pharmacy.
Disposable devices – such as continuous glucose monitor (CGM) sensors and patch insulin pumps – are typically covered under the plan formulary and purchased at the pharmacy. Note patch pumps in particular may be found on either list.
If you are switching to a new network or PBM, definitely check to ensure all of your devices and their related supplies are covered. Some plans limit the types of pumps or CGMs they’ll cover. Accordingly, they may limit supplies to those devices. If supplies are limited to a device that’s different from what you are using, I suggest appealing immediately as the plan will likely make that exception rather than give you a new pump, for example. (These guys are good at math when it’s in their favor.)
To recap, make sure your Doctors, Drugs, and Devices are covered under any plan you are considering. Places to find that information include the plan website which should show you a list of doctors and other health care providers they cover. You should also be able to find a link to the plan formulary to look up the drugs that you need to see if they are covered and at what copay. You may need to call an 800 number (1-800-dial-a-prayer?) to get answers on device coverage and prior authorizations. Take the time to figure this out before you are out of your insulin or supplies.
Now, take a breath, resist the urge to self-medicate, and start reviewing the lists!
Demystifying Health Insurance Part 1: How to Pick a Plan with the Lowest Total Cost
Demystifying Health Insurance, Part 3: Decoding Health Insurance Plans
What You Need to Know About Navigating Insurance and Changing Plans
I’m interested in getting the Omni pod 5. My insurance doesn’t cover novolog insulin. Why is that insulin the only one used in the pump. Why can’t I just use my humalog kwik pen. Can you help me with this? Thank you for doing such a great service.
I think you may be misinformed. You can use Novolog, Humalog, Fiasp, or Lyumjev in your pump. I use Humalog in my Omnipod.