A doctor holds a clip board while speaking to a mother and daughter.

Checklist: Using Health Insurance

You have health insurance, but do you know how best to use it? This checklist provides helpful tips to make sure you get the most out of your health insurance coverage.

Have the right insurance

  • You should have a health insurance plan that works for you. As your health needs change, you may want to change your insurance. You should check every year, during open enrollment, to see if your plan still costs the least and covers your providers, prescriptions, health care facilities, and pharmacies.
  • To figure out which health insurance plan is best for you, watch our short video on How to Pick a Plan, and see our other resources.

Use in-network providers & pharmacies

To keep your health care costs lower, use in-network providers and pharmacies when possible:

  • Health care providers, health care facilities, and pharmacies contract with health insurance companies and agree to accept a specific rate for their services under a plan. These providers and facilities are then considered “in-network.”
  • Health insurance companies often provide a list of in-network providers on their website, but you can also call them to find in-network providers.
  • If you choose to go to an out-of-network provider, it is likely that your plan will not pay for the care that you received. But you may have a plan that pays some of your out-of-network care. In this case, the provider can bill you for the balance of the bill that is not covered by your insurance. This is called “balance billing.” An in-network provider cannot balance bill.
  • Surprise bills happen when you think that you are going to an in-network provider, but later find out that a member of your health care team is out-of-network, leaving you with a surprise bill. If you get a surprise bill, there is a federal law that protects you. Learn more about the No Surprises Act online, or by calling 800.985.3059.

Get pre-authorizations

  • Health insurance companies may require you to get their approval before you receive certain medical care, including treatments, lab tests, imaging scans, medical devices, and prescription drugs. This can also be called prior authorization, pre-auth, prior auth, prior approval, pre-certification, or a treatment authorization request. These are some key steps to getting pre-authorization:
    • Ask your health insurance company to find out if the care you need requires pre-authorization and the process to get it.
    • Ask your health care team to find out if they will get the pre-authorization from your insurance company, or if you will have to do that.
    • Complete and submit your forms on time. Many insurance companies have deadlines! Make sure you start the pre-authorization process as soon as possible to make sure your medical care is not delayed.
    • Always keep a copy of your pre-authorization request in case the request is lost.

For details about prior authorizations, visit the Triage Cancer Quick Guide to Pre-Authorizations.

Ask for exception requests for your prescription drugs

  • A formulary is the list of drugs that are covered by your insurance plan. Formularies are broken down into different levels or “tiers” depending on how much you will have to pay out-of-pocket for a drug. Your insurance plan will likely not cover a drug that is not on the formulary. But there are exceptions:
    • If a prescription drug that you need is not on the formulary, you can ask for an exception request.
    • If a brand name prescription drug that you need is not covered, but the generic version is, you can request a brand exception.
    • If a prescription drug that you need is in a formulary tier that costs you more, you can request a tier exception.
  • Some insurance plans require your doctor to submit the exception request for you, while some allow you to submit it yourself. Your plan may have a form for you or your doctor to fill out. Your doctor can help provide information on why you need to take a specific drug.
  • Common reasons for formulary exceptions include:
    • You had an allergic reaction to the drug.
    • The drug has known adverse interactions with another medication you are taking.
    • You tried the drug and it didn’t work.

Appeal when an insurance company says no

  • It is common for an insurance company to deny coverage for your care. But, you do not have to take no for an answer. If you have a private insurance plan, you have two chances to appeal a denial of coverage: an internal appeal and an external appeal.
  • Internal Appeals: You can start by filing an “internal appeal” with your insurance company. Each company has their own process, so ask them or look for instructions on how to file an appeal on your denial letter.
  • External Appeals: If your insurance company denies your internal appeal, you can request an external appeal, otherwise known as an External Medical Review or Independent Medical Review.
  • If you have not yet received care, and it is urgent, you can file an urgent internal and external appeal at the same time and it is supposed to be decided within 72 hours.
  • Pay attention to deadlines, to make sure that you do not miss your chance to appeal
  • For more information about appealing an insurance company decision, visit the Cancer Finances Module on Appeals.

Stay organized

  • When dealing with your medical care and the paperwork that comes with that care, it is very helpful to stay organized.
  • There are lots of tools to keep track of your medical bills, paperwork from your insurance company such as the explanation of benefits (EOBs), medical records, and other paperwork. But the key is to use whichever tool is going to make it easier for you to stay organized, whether that is a box with file folders or a 3-ring binder.
  • If you need to appeal any denials of coverage, you can use the Triage Cancer Appeals Tracking Form.
  • Triage Cancer also offers a webinar on Healthy Organizing.

For more information, visit our Health Insurance topics page.

Last updated: 1/23

Disclaimer: This handout is intended to provide general information on the topics presented. It is provided with the understanding that Triage Cancer is not engaged in rendering any legal, medical, or professional services by its publication or distribution. Although this content was reviewed by a professional, it should not be used as a substitute for professional services. © Triage Cancer 2023

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