Health Insurance for Asthma Patients

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

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

2. Are the asthma medications you need covered?

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

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

Read: What you need to know about prior authorization >>

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

Most health plans pay an independent company to manage their drug benefits. These companies are called pharmacy benefit managers (PBMs). PBMs decide which drugs are included in 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 manufacturers and pharmacies, decide what patient copays or other costs should apply, and set rules for access to specific drugs. PBMs sometimes operate specialty or mail-order pharmacies that health plan members are encouraged (or required) to use.

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

4. What is the process to get coverage for your medication?

If your health plan requires prior authorization for your drug, you will need to get your permission before they will pay for it. The process to obtain that permit can be confusing. The health care professional who prescribed the medicine will usually help you. They will have to fill out a form and explain the reason why they prescribed that medication. The health plan may follow up with the HCP to get more information.

If the health plan denies your request, you generally have the right to appeal. The plan must give you information about how to make an appeal. Again, your doctor or office can help you. The appeal may include more details from you and/or your doctor about why the medication is necessary for you. Your doctor may need to show you how the treatment fits into standard treatment guidelines or why you need something different.

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

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

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

For covered drugs, you generally pay a copayment, a flat fee, each time you fill a prescription. The amount of that copayment may depend. For example, there are usually different copayments or other costs for drugs depending on how the plan classifies them, called “tiers.” Tier 1 drugs may have the lowest copays and fewest restrictions. Higher tier drugs may cost you more and have more rules or obstacles.

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

In addition to co-pays, other factors can affect your costs. If you have a deductible, you will have to pay the full cost of the drug until you meet the deductible.

Your health plan may also have a limit on the total you pay out of pocket each year, called the “out-of-pocket maximum.” If you reach that limit, you will not have to pay any more copayments. But check the details: These limits may not apply until you’ve paid many thousands of dollars.

6. What is the policy on coverage of new treatments as they become available?

When looking for health insurance options, check the policy to cover new treatments when they become available. You can’t know for sure which drugs your health plan will cover in the future, 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.

You can also search health plan ratings to see how other people rate the plan, specifically on how easy it is to access needed care. Although it won’t predict what your specific experience will be, it can give you an idea of ​​how other people feel about the plan’s coverage policies.

7. What is a specialized pharmacy?

Some medications are not available at a typical retail or mail-order pharmacy. Medications that are not used very often, need special handling, are injected or infused, or require special monitoring may only be available at a specialty pharmacy.

Specialty medications may be more restricted and expensive. You may need to follow specific rules or procedures to obtain them. Some asthma medications fall into this category.

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