Getting appropriate coverage is vital for people who require specialty medications. When enrolling in new coverage, it is important that you understand what benefits are covered and what your costs will be. Before purchasing any plan, carefully evaluate the following:

Benefit Summary:

Health insurers and group health plans are required to provide you with an easy-to-understand summary of the coverage they provide.

What is a drug formulary?

Health insurers maintain a list of preferred prescription drugs that are covered through their health plan, often known as a formulary, Preferred Drug List, or PDL. The PDL classifies drugs by different cost tiers that define the member’s copay amounts and/or coinsurance levels.

What is a provider network booklet?

The Provider Network Booklet provides the list of healthcare providers that have contracted with the health plan to provide services to their members, at an agreed-upon rate. Depending on the plan, members who receive care from providers not included in the network may have little or no coverage for that provider and/or services received. Review the provider network for each plan you consider to ensure your doctors and other service providers are in-network.

You may find that you have the option to choose between multiple plan types and designs such as HDHP, HMO, PPO, POS, or EPO.

What is a HDHP (High-Deductible Health Plan)?

This is a plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more of the healthcare cost before the plan starts to pay its share (your deductible). An HDHP that meets federal standards for a minimum deductible can be combined with a health savings account (HSA) to allow you to pay for qualified out-of-pocket medical expenses on a pre-tax basis.

What is a HMO (Health Maintenance Organization)?

This plan usually limits coverage to contracted doctors within the HMO and will require a referral to see a specialist. Generally, HMOs won’t cover out-of-network care, except in an emergency, and may require you to live or work in a service area to be eligible for coverage.

What is a PPO (Preferred Provider Organization)?

PPO plans are created by a network of participating providers. You pay less if you use providers who belong to the plan’s network. You can use providers outside of the network for an additional cost.

What is a POS (Point-of-Service Plan)?

This type of plan allows you to pay less if you use doctors, hospitals, and other healthcare providers that belong to the plan’s network. POS plans may require you to get a referral from your primary care doctor to see a specialist.

What is an EPO (Exclusive Provider Organization)?

EPOs are like HMOs, except that individuals may not need a referral from a primary care physician to see a specialist.