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In most situations, using your insurance coverage is in your best interest because it ensures you are receiving the maximum benefits that you are entitled to, and utilizes what you are paying for with your premiums. But, in some cases, you may choose to pay directly for the care you want and forgo your insurer’s assistance and insurance policy. We have highlighted a couple of instances where you might choose to forfeit any insurance intervention.
Margaret’s doctor prescribes a high blood pressure medication necessary for her care. Her insurer requires prior authorization, so her doctor submits the request to her insurance company. Her health plan denies the request because it is not on the formulary. Margaret’s doctor starts the appeals process, as her doctor is confident this medication has the ability to help her feel better. He explains that the appeals process could be lengthy and tells her she should start the medication as soon as possible.
What can Margaret do?
• Opt to pay for the medication privately
• Shop around at different pharmacies to get the best price (websites like goodrx.com can show her, based on her specific location, which local pharmacy has the best retail price)
• Utilize medication discount cards, like one available from NeedyMeds.com or goodrx.com to help further lower the cost.
As well, lots of manufacturers offer free drug programs. If she is approved based on the criteria of the program, Margaret may still have access to the medication, and actually at little or no cost to her.
Pro: Margaret was able to get the medication she needed immediately
Con: If Margaret spends any money on her medication, that money does not count towards meeting her deductible or out-of-pocket maximum associated with her plan.
Steve has a great relationship with his long-time cardiologist, but his doctor makes the decision to leave his insurance network. Steve’s plan does have out of network benefits, but the plan only pays at 50% while his in-network benefits pay at 80%. Steve can still continue to see his doctor, but he does have the option to pay cash instead of utilizing his insurance benefits. So, Steve speaks with the billing coordinator at the cardiologist’s office and asks that the doctor’s office work with him financially. He tells them his health insurance will not be paying towards the cost of the visits but he would still like to remain a patient. The office may offer him what’s called a self-pay discount, where the office would reduce the charges since he is now paying without any health coverage.
Pro: Steve is able to continue receiving care from the doctor he prefers
Con: Any money Steve pays towards his visits does not count towards his plan’s deductible or out of pocket maximum. Also, if his doctor is not in-network, Steve will need to pay close attention to the other services this doctor coordinates for him. It’s a strong possibility that any lab work, referrals, procedures, or facilities that are recommended might also be out of network for his plan.
This information is part of the “It Matters Empowerment Pathways” content series developed as part of the Matters of the Heart project.