Each year, insurance companies review costs for services and treatments they cover and often make adjustments for the following year. It’s important to review your plan each year during open enrollment season to make sure you don’t lose coverage for PH treatments and specialist visits.
Contact your health care team and specialty pharmacy as soon as you learn about changes to your plan.
- Employer switches insurance carriers
- Changing or leaving a job
- Turning 18, 26 or 65
- Marital status changes
- Disability
Why your coverage might change
If your employer changes insurance providers, or the insurance provider makes changes to the plans offered, read the new policy carefully and ask the new insurance company whether it covers your PH medications or treatments. If the new plan doesn’t cover your PH therapies, work with your health care team to file for a medical exception or appeal.
If you lose your employer-based insurance, you have the right to continue group health benefits for a limited time through COBRA, or the Consolidated Omnibus Budget Reconciliation Act.
Turning 18: People who received Supplemental Security Income as children must reapply for benefits when they reach adulthood. The Social Security Administration usually will contact beneficiaries within a year of turning 18. The agency will ask for information about your disability to determine whether you qualify for benefits as an adult.
Turning 26: Young adults age 25 or younger can receive coverage through their parents’ health insurance plans. When you turn 26, you become eligible for COBRA, which allows you to pay to keep your current health insurance for a limited time.
Turning 65: Adults become eligible for Medicare.
Your insurance coverage could change when you marry or divorce or if you receive insurance benefits through a spouse who retires or dies. If you know about an approaching transition, explore your options early.
People who receive Social Security Disability benefits become eligible for Medicare after two years. Social Security allows beneficiaries to work up to nine months, consecutively or non-consecutively, over a five-year test period while receiving Medicare insurance and Social Security income.
If you earn too much to continue qualifying, your benefits will stop. However, you have five years to ask SSA to reinstate your disability benefits if you stop working again. You won’t have to wait to receive benefits while SSA reviews your case.
Your free Medicare Part A coverage will continue for 93 months after the trial work period. You also can pay a monthly premium to keep Part B. After the 93 months, you can receive Medicare parts A and B if you pay monthly premiums for each.
Compare your insurance options
If your insurance changes for any reason, and you can choose among plans, make sure you compare plans. Get started by listing medications and medical care you expect to need in the coming year, such as routine tests, specialist appointments or hospitalizations.
Next, gather information about each plan available to you. List each plan’s premium or monthly cost and compare:
- Whether a plan requires you to pay a deductible before coverage begins. If so, note the deductible amount.
- Whether a plan includes prescription drug coverage. If you need to buy a separate prescription plan, note its monthly premium.
- Whether each plan covers the appointments or tests on your initial list. Note how much each plan covers. Will your specialists be in-network under plan? Does the plan limit how many hospital nights it will cover?
- The cost-sharing responsibility for your prescriptions under each plan. Note whether you pay a set price (copay) or a percentage of the cost (coinsurance).
- Whether the prescription formulary includes your PH drugs or treatments, and whether the plan’s pharmacy network includes the specialty pharmacy that delivers your PH medications.
After gathering the information, add each plan’s costs from the steps above, and compare plan options by total costs.
Plans with more expensive premiums often cover more services or cover them at higher rates. Higher-premium plans might be better options than lower-premium plans, depending on your expected costs for the year.
Video: Choosing an insurance option
Fran Rogers, MSN, CRNP, suggestions questions to ask when choosing an insurance plan.
Review your prescription coverage
Insurance companies regularly change their formularies, or list of covered drugs. They often change the formularies at beginning of a new plan year, but they also can make changes mid-year.
Some reasons why formularies can change during the year:
- Drug therapies change.
- New drugs are approved.
- New medical information becomes available.
Insurance companies also can remove drugs from their formularies, a practice known as drug exclusion. Or they could shift a drug to a lower or higher tier, which could affect your copay.
What to do if your prescription coverage changes
If you learn that your medication coverage is changing, contact your health care team to discuss your options.
If you or your prescriber believes no drugs on your plan’s drug list will work for your condition, you can ask for an exception to cover a drug not on the list or waive a coverage rule. If your drug is on the list but moved to a higher, non-preferred tier, you can request a tiering exception so you’ll pay a lower amount.
To request a medical exception, work with your health care team to submit a letter of medical necessity to the insurer. Most health plans require specific forms. They also need evidence that all covered Part D drugs on the formulary tiers are less effective or would harm your health. Review the Centers for Medicare and Medicaid Services’ information about the medical exception process.
Learn about Medicare Part D coverage
Are you eligible for Medicare Part D prescription drug coverage? Find out how to enroll or choose a plan.
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