“Is this covered?” is one of the most common questions I get from members wondering about seeing a new doctor, changing medicines or trying a new treatment option. And I’m always happy when they call and ask me before using services to avoid an unpleasant surprise when they get the bill.
Questions to ask to figure out if it’s covered:
What does “covered” mean anyway?
If a service is covered, it means your health plan will pay for some or all of the cost. In most cases, your doctor also needs to be on the list of doctors that take your insurance, called a network. How much your health plan pays for depends on what type of care you use and where you get it.
- Some covered services are completely free to you, like going to the doctor for your annual exam. Your plan pays everything.
- For others – like seeing the doctor for a lingering sinus infection or filling a prescription for covered antibiotics – you’ll pay a fee. The amount you pay will be different depending on the type of plan you have and whether or not you’ve taken care of the amount you have to pay before your plan starts helping you (your deductible).
Log on here to check your deductible.
To get the biggest bang for your buck, use services your health plan covers whenever possible.
How do I know what’s covered?
Every plan – even plans through the same insurance company – covers different doctors, clinics, prescriptions and other services. This is often because there are different types of plans to choose from. Some members are surprised to learn that their plan covers things they didn’t expect, like their chiropractor visits and pumps for breastfeeding moms. Check that the care you want is covered – and the amount you’ll have to pay – before you make an appointment.
Here are four places to go for info:
1. Your Summary of Benefits and Coverage: Log onto your online account through your insurance company, and look for a link to your plan’s Summary of Benefits and Coverage, sometimes called an SBC. This is a standard document that all plans are required to have. It lists the services the plan covers and how much (see a sample SBC).
Your My plan tab summarizes this information for you. Log on now.
2. Your doctor search tool: Log into your online account, and look for a link to your plan’s network, provider or doctor search tool. Different plans cover different doctors, specialists and clinics – called the plan’s network. Check that the doctor you want to see is covered.
Click here to see the doctors your plan covers.
3. Your list of covered drugs: Log into your online account, and look for a link to your plan’s preferred drug list. All plans have a list of the prescriptions they cover. Search the list to make sure the prescriptions you need are included. Some plans also offer a calculator tool to help you find the lowest prices on prescriptions from specific pharmacies or in different quantities.
Sometimes you can get fewer pills at a higher dose and split them yourself to save money. Always talk with your doctor about this option and the correct way to do this.
4. Call or e-chat with a member services representative: There’s no such thing as a silly question. If you have any questions about what your plan covers, call your insurance company. Member services representatives are there to answer exactly these types of calls. They can tell you whether a doctor, prescription or service is covered and how much your insurance will pay.
You’re reading the “Getting Started With Your Plan” series.
Have a health plan but not sure what to do next? This series can help you get started.