Things you should know before you buy Health Insurance

I have been working as a pharmacy technician for over 11, currently I work for a PBM (Pharmacy Benefits Management) company. I get calls every day from very upset members and the reason, they are miss inform with their benefits.

Bottom line is YOU the members’ responsibility to read and understand your insurance plan but must important your benefits.

Under the pharmacy benefits you should asked some of these questions:

• Copay structure for medications including local pharmacy and mail order pharmacy.
• Do you have mail order benefits and the name of the pharmacy they use as mail order.
• Maximum day’s supply you can get at local retail pharmacy and mail order pharmacy.
• If mail order pharmacy is mandatory on maintenance medications.
• Deductible and the amount, and if is per family or individual.
• Maximum benefits per year if any
• Out of pocket amount if any
• Which medications required Prior Authorization i.e. Singulair, ADD or ADHD medications, Injectables, Cosmetic drugs, Smoking Deterrents, PPI’s, etc.
• Medications that have quantity limits and what is the quantity i.e. Viagra, Cialis, Levitra, Imitrex, Relpax, Zomig, Oxycontin, Kadian, Ambien, Lunesta etc.
• Maximum dollar amount allowed per prescription, usually if the prescription cost is over that amount required Prior Authorization.
• Pharmacies in network.
• If the plan allow reimbursement and time frame to submit claims, usually is 365 days, if is allowed in pharmacies that are out of network
• If is mandatory to use a specialty pharmacy for injectables, if yes asked the name
• If you are a diabetic always ask for diabetic supplies, glucose meter, test strips and lancets
• If generic medications are mandatory
• The FORMULARY, with this list you will see which medications are preferred or non preferred under the insurance. Usually non preferred medication you can get them but with a higher copay.

Ask questions and don’t assume.