By Leslie J. Vaughan, R.Ph.
This time of year, most of us are focused on the holidays - spending time with family and friends and looking forward to ringing in the New Year! With all the fun and frivolity, it may be easy to forget that, for many of us, the start of the New Year also means restarting the insurance benefit year. And, for those of us on high-cost therapies, this means we may have a large out-of-pocket responsibility in the first one or two months of the year.
If you have already completed open enrollment, you should have a pretty good idea whether or not your premiums will change. In addition to your premiums, it is a good idea to check into other aspects of your insurance coverage to financially plan for the start of the year. Take a few minutes to review your coverage and benefits. You should be able to find most of this information on your insurance company’s website, or you can call the member customer service line listed on your card. Here are a few items to check:
Deductible: Your deductible is the amount you are responsible to pay before your insurance will begin covering any portion of your medical expenses. Depending on the type of plan you have, the deductible may be in the low hundreds, or it may be very high if you have a high deductible HSA plan.
Percentage of coverage: Most insurance plans begin to cover a portion of your medical expenses after you have met your deductible and you remain responsible for the non-covered portion. This is expressed as a percentage. For example, your coverage may be 80/20, which means the insurance company will pay 80 percent of charges, and you will be responsible for the additional 20 percent.
Maximum out of pocket: This is also known as a “stop loss.” If your plan has a stop loss, once you have paid a total dollar amount, the insurance begins to pay 100 percent.
Coverage limitations, exceptions and exclusions: Some insurance plans have limitations, or exclusions, on certain items. For example, a plan may only pay for a certain number of nursing visits per benefit year, and once those visits are used, you become responsible for the cost of additional visits. Some services may be excluded completely. Check your plan document to obtain more detail on what is and isn’t covered by your plan.
For those new to Medicare Part D, there are four phases of coverage to understand. Coverage under a standard plan is outlined below Part D. Premiums vary by the plan you select and may range from $0 to $75. Deductibles, copays and coinsurance also vary by the plan you select. For 2014, these are:
Initial Deductible: You pay 100 percent of $310.
Initial Coverage Limit: Plan pays 75 percent and you pay 25 percent for a combined total out-of-pocket expense of $2,850.
Coverage Gap (donut hole): You pay 100 percent, which begins once you reach your Medicare Part D plan’s initial coverage limit ($2,850 in 2014) and ends when you spend a total of $4,550 (known as the out-of-pocket threshold). Part D enrollees will receive a 52.5 percent discount on the total cost of their brand-name drugs while in the donut hole.
Catastrophic Coverage Portion of the Benefit**: This is the greater of 5 percent, or $2.55, for a generic or preferred drug that is a multi-source drug, and the greater of 5 percent, or $6.35, for all other drugs in 2014.
The last thing to keep in mind is the need for prior authorization for immune globulin (IG). If you are changing plans, your new plan may require you to obtain prior authorization. Each insurance company has different criteria based on diagnosis for approving treatment with IG. New authorization may take several weeks to obtain if you are changing plans, which may cause a delay in treatment.
If you have specific questions about your plan, contact your NuFACTOR representative for help in getting answers.