Before your talk with your insurance provider, take a look at your plan and develop an understanding of what is covered. To do this, look at your list of benefits, or medical services that are covered. You may also find a list of closed benefits, which means your provider will not pay for the cost of any treatment not on the benefit list.
On top of a benefits list you may find a “formulary,” which is a list of prescription drugs the health plan covers. It can include medications that are both brand name and generic. An “open formulary” or “preferred drug list” often has a greater choice of covered drugs. A “formulary exclusion list” is a list of prescription drugs not covered by a health plan. If you need a treatment or drug that is not on your benefits list or formulary, you and/or your doctor must ask the plan to cover it as an exception. Even if your prescribed medication is on your plan’s formulary, it will only cover that drug if it is deemed medically necessary through standards or research that states what care is most effective.
“Medically necessary” can also be referred to as “medically necessary services” or “medical necessity.” To keep track of what services your provider has covered and what money you may owe them, you can review your explanation of benefits (EOB) — a statement usually sent by mail or email from your health plan. You may find you owe money through a copay or coinsurance fee. Coinsurance is the percentage of health care expenses you pay after your deductible. Copay is the dollar amount you pay for health care expenses, most often after you meet your deductible limit.
When you speak with your insurance provider on the phone, be sure to have a good understanding of what your plan covers. If certain medications or treatments are deemed necessary by your doctor but not covered, there are appeals processes you can make to prove medical necessity.
For more information on how to talk to your insurance provider, go here: http://www.ghlf.org/switching-survey-glossary/