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How Does Prescription Insurance Work?

How Does Prescription Insurance Work_

Medical insurance is a contract with an insurance company, according to which you pay a certain contribution every month, and the insurance company helps you to smooth out medical expenses, when and if necessary. Buying medical insurance, you protect yourself from unexpectedly high costs in case you need medical attention. Many people wonder if insurance plans cover prescriptions and how prescription insurance works. Read this article to find out the answer.

Differences in health insurance plans

Health insurance can be very different. Their main differences are listed above:

1. Type of insurance – most insurance companies offer insurance such as HMO and PPO

2. An insurance network – this is medical facilities, pharmacies, and specific doctors who have an agreement with your insurance company. For example, you come to the clinic, and they “do not accept” your insurance. It happens. The services of doctors and hospitals that are not part of the plan network can cost you a lot more. Each time before visiting a new doctor or clinic, you need to check “what insurance they accept.” Naturally, the plans of the most popular insurance companies are accepted almost everywhere.

3. Premium is the amount of the monthly insurance premium. Premium is different for all plans and can vary from $180 to $500 (per person)

4. Non-refundable or uncovered expenses are a very important point. These are the costs of medical care that you pay yourself and which are not reimbursed by the insurance plan:

  • Co-pay is a fixed amount that you pay for each visit to the doctor, for a medicine or other service. The remaining cost is covered by your health insurance plan. For example, $40 for a visit to a specialist doctor, or $100 for a visit to an emergency center. The rest is covered by insurance. Some plans do not provide co-pay;
  • A deductible is how much you need to pay before the insurance coverage starts. In some plans, Deductible is not provided. A deductible may not apply to all medical services – for example, it usually does not apply to preventative services (vaccinations, routine examinations);
  • Co-insurance – you pay a certain percentage (for example 20%) of the cost of the service, and the rest is covered by your health insurance plan;
  • Out-of-pocket maximum limit is the maximum amount that you may need to pay during the year. If you have already paid your out-of-pocket, then all of these Co-pay, Co-insurance and Deductible lose their meaning and the insurance starts to cover 100% of all your expenses. This is a very important factor!

5. Coverage of services and prescriptions – each insurance plan has a very long and detailed list of services, procedures and medicines that it covers and which does not cover. Some insurances cover dental and ophthalmic services but they are not included in most plans. An insurance plan usually comes to you with a whole book of hundreds of pages (Summary of Benefits) listing everything covered by the plan, and on the insurance company’s website, you can usually dig into the database of covered drug plans. It is likely that your medicine is not covered by any plans (in this case, you can try to find a covered analog). This “coverage” needs to be carefully examined before concluding an agreement.

You also need to know about Essential Plan’s new program. This is a government program with a minimum monthly payment of only $20. The program is free for families with incomes below 138% of the federal poverty level. A person with an Essential Plan can afford regular preventive examinations, visits to a specialist, and paying for prescription drugs.