Health Insurance 101: How to Choose Health Insurance if You Have Asthma

1. Does the provider network include a range of asthma specialists?

Check the plan’s provider directory to make sure your healthcare providers (HCPs) participate in the health plan’s network. Even if you don’t see an asthma specialist today, you might need to in the future. Make sure the plan offers a range of specialists available.

2. Are the asthma drugs you need covered?

It may seem like a simple question, but whether your health insurance covers a specific medication can be complicated to answer. The first step is to check the preferred drug list (PDL) or “formulary,” the list of drugs that your health plan covers.

If the drug is on that list, that’s not the end of the story. Even covered medicines can be subject to rules such as prior authorization. That means you may have to get permission from your health plan before they’ll pay for the drug. If they deny your request, you can appeal. You might win, but there’s no guarantee.

Read: What You Need to Know About Prior Authorization >>

3. How do health plans decide which medications are covered?

Most health plans pay a separate company to manage their drug benefits. Those companies are called pharmacy benefit managers (PBMs). PBMs decide which drugs go on the PDL. Coverage decisions may be based on data about cost, effectiveness, available alternatives (if any), and generally accepted treatment guidelines.

PBMs also negotiate drug prices with drug makers and pharmacies, decide what patient copayments or other costs should apply, and set rules for access to specific drugs. PBMs sometimes manage specialty or mail-order pharmacies that health plan members are encouraged (or forced) to use.

Read: Pharmacy Benefit Managers Are the Most Influential Healthcare Companies You’ve Never Heard Of >>

4. What is the process for getting coverage for your medicine?

If your health plan requires prior authorization for your medicine, you’ll have to get their permission before they’ll pay for it. The process to get that permission can be confusing. Usually, the HCP who prescribed the medicine will help. They’ll need to fill out a form and explain their reasoning for prescribing that medication for you. The health plan may follow up with the HCP for more information.

If the health plan denies your request, you usually have the right to appeal. The plan has to give you information about how to file an appeal. Again, your HCP or their office may help. The appeal may include more details from you and/or your HCP about why the medicine is necessary for you. Your HCP may need to show how the treatment fits within standard treatment guidelines, or why you need something different.

Sometimes you have the right to more than one level of appeal. You may be entitled to ask an external reviewer to look at your health plan’s decision and consider overturning it.

Plan-specific and state rules vary. Check your member handbook or ask the health plan customer service for step-by-step instructions for submitting a prior authorization request, and if necessary, an appeal. Your state’s insurance commission may help if you get stuck.

5. If your medicines are covered, how much will they cost you?

For covered medicines, you usually have to pay a copayment, a set fee every time you fill a prescription. The amount of that copayment can depend. For example, there are usually different copayments or other costs for drugs depending on how the plan categorizes them, called “tiers.” Tier 1 drugs might have the lowest copayments and fewest restrictions. Higher-tier drugs may cost you more and may come with more rules or hurdles.

Specific drugs may also be considered “preferred” or “non-preferred,” which may influence how much the drug costs you and how easy it is to get. The PDL should include these designations, if applicable.

In addition to copayments, other factors can affect your costs. If you have a deductible, you’ll have to pay the full drug cost until you meet the deductible.

Your health plan may also have a cap on the total you pay out of pocket each year, called an “out-of-pocket maximum.” If you reach that cap, you won’t have to pay any more copayments. But check the details — these caps may not kick in until you’ve paid many thousands of dollars.

6. What’s the policy on covering new treatments as they become available?

When you’re looking at health insurance options, check the policy for covering new treatments when they become available. You can’t know for sure what future drugs your health plan will cover, but you can at least read their policy about how they decide which ones to cover. Ask the customer service team for that policy if you can’t find it easily.

7. What is a specialty pharmacy?

Some medicines aren’t available through a typical retail or mail-order pharmacy. Medicines that aren’t used very often, need special handling, get injected or infused, or require special follow-up may only be available from a specialty pharmacy.

Specialty drugs may be more restricted and costly. You may have to follow specific rules or procedures to get them. Some asthma medications fall into this category.

Read your health plan documents for information about how to get specialty drugs if you need them. Your insurer may require you to use their preferred specialty pharmacy.