Open enrollment comes at a busy time of year, so it can be tempting to rush through the process. But investing a few minutes now to understand the options is the best way to ensure optimal care in the new year.
In addition to looking at premiums and coverage levels, enrollees should consider these five components:
1. The Formulary
Every plan has a formulary of medications they cover and others they don’t. People picking a new plan should check to see if the medications they take are included. People planning to continue with last year’s plan should also review the 2021 formulary. Just because a medication was covered this year, doesn’t mean it will be covered next year.
In fact, changes in health plan formularies can result in non-medical switching, where stable patients must switch to a plan-preferred medication. Non-medical switching occurs when health plans remove certain medications from the formulary or shuffle medications to a different coverage tier, pricing patients out of access.
As research shows, non-medical switching can hurt patients’ health as well as their quality of life.
2. Provider network.
Just like plans have a list of preferred medications, they also have a list of preferred health care providers. Seeing an “in-network” provider will cost the patient and the insurer less, so it’s important to see if your regular providers are in network.
Reviewing which medical specialists each plan covers is also worth the time. People living with headache and migraine disease, for example, may want to confirm which neurologists or headache providers are in network. This can be doubly important because some insurers limit the ability to prescribe certain treatments to providers with specific certifications.
3. Cost sharing.
Out-of-pocket costs for health care vary widely depending upon a health plan’s approach. It’s important for patients to understand which services and medications require a co-pay, a flat and generally modest dollar amount, and which require co-insurance, a percentage of the service or medication’s cost.
High cost sharing keeps patients from seeking care when they need it and from taking their medications as prescribed. It pays to know when an out-of-pocket payment is required, whether it’s a co-pay or co-insurance, and if the rate will change in the new year.
4. Co-pay card rules.
People who use co-pay cards to help pay for expensive medications should find out whether their plan counts the co-pay cards’ value toward their annual deductible.
More and more plans now use what are known as co-pay accumulator adjustment programs, which allow patients to use co-pay cards but don’t count them toward the annual deductible. Patients who don’t know their health plan’s rule on co-pay cards may end up surprised by a massive pharmacy bill when the card’s balance is exhausted.
Insurers use a variety of names for these programs, including co-pay accumulator adjustment program, benefit plan protection program and out-of-pocket protection program.
5. Coverage for new drugs.
New medications come to market year-round, but health plans may not cover them right away. Instead, some plans “just say ‘no,’” forcing patients to wait months, or even until the next calendar year, before they can get the new medication. The approach is called a new-to-market exclusion.
Waiting is hard for everyone, but for patients with rare or hard-to-treat diseases these delays can allow their disease to worsen. New-to-market exclusions are particularly frustrating when there are no other treatment options available.
Picking the right health insurance plan can be tricky. But understanding how each plan addresses these five elements can help people have confidence in their selection.