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A national 501 (c)(3) non-profit charity that provides direct services to patients with chronic, life threatening and debilitating diseases to help access care and treatment recommended by their doctor.
Reading and understanding your insurance plan’s keywords and phrases will help you uncover ways to control costs.
Covered Benefits A comprehensive medical policy contains several areas of coverage; however no plan will cover everything available in the healthcare world. Before you seek care become familiar with your covered services identified in the plan language. You may be surprised to find the services you need are not covered or are only covered with approved pre-authorization.
Non-Covered Benefits and Exclusions No insurance plan will pay for everything, so it’s important to read and become familiar with the section of your health policy that lists the limitations and exclusions. These are the services your insurance won’t pay for.
Typical limitations or exclusions include eye exams and contacts, dental care, fertility treatment, cosmetic surgery and alternative or complementary care (such as massage). Some plans will limit coverage for treatments the insurer considers unproven. This can include supplies, procedures, therapies or devices considered experimental or investigational.
Pharmacy Benefits In order to fill a prescription drug, most insurers require a co-pay (a fixed cost) or co-insurance (a percentage of the cost) paid beforehand. These costs can vary greatly depending on which tier level the medication is classified on within the plan drug formulary. The higher the tier level (tier levels usually range from 1 to 5), the higher the out-of-pocket cost associated with that medication.
You may also have to meet a pharmaceutical deductible amount before your insurance begins paying anything toward your medications. Generics are usually on lower tiers and can be used to save money when available.
If you need a medication that is not included on the formulary, you can request that your doctor contact the health plan to explain the medical need for you to take a specific medication. If your request is denied, you have the right to appeal your health plan’s decision.
Keep in mind that it’s OK to ask about costs when you’re considering treatment options. Some treatments may be more cost-effective and just as powerful in treating your condition as others.