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Health Insurance 101: How to Choose Health Insurance if You Have Asthma
7 questions to explore when you’re evaluating health insurance options for asthma care
Apr 02, 2024
Apr 29, 2024
Your CareDeborah D. Gordon has spent her career trying to level the playing field for healthcare consumers. She is co-founder of Umbra Health Advocacy, a marketplace for patient advocacy services, and co-director of the Alliance of Professional Health Advocates, the premiere membership organization for independent advocates. She is the author of "The Health Care Consumer's Manifesto: How to Get the Most for Your Money," based on consumer research she conducted as a senior fellow in the Harvard Kennedy School's Mossavar-Rahmani Center for Business and Government. Deb previously spent more than two decades in healthcare leadership roles, including chief marketing officer for a Massachusetts health plan and CEO of a health technology company. Deb is an Aspen Institute Health Innovators Fellow, an Eisenhower Fellow and a Boston Business Journal 40-under-40 honoree. Her contributions have appeared in JAMA Network Open, the Harvard Business Review blog, USA Today, RealClear Politics, The Hill and Managed Care Magazine. She earned a BA in bioethics from Brown University and an MBA with distinction from Harvard Business School.
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7 questions to explore when you’re evaluating health insurance options for asthma care
If you have asthma, choosing the right health insurance can help you get the treatments you need with less hassle.
Asthma treatments fall into two main categories:
For people with allergies that trigger their asthma symptoms, allergy medicines can also help.
Common medicines, such as corticosteroids, reduce inflammation in the airways. Newer drugs called “biologics” are made with cells from living organisms and interfere with inflammation in the first place.
Read: You Don’t Have to Live With Uncontrolled Asthma >>
Depending on your insurance coverage, the drugs you need can be easier (and cheaper) or harder (and more expensive) to get. Make sure you understand what asthma care your health insurance covers.
Whether you get your health insurance through a job or a government program, here’s what to look for when you’re choosing a plan.
Check the plan’s provider directory to make sure your healthcare providers (HCPs) participate in the health plan’s network. Even if you don’t see an asthma specialist today, you might need to in the future. Make sure the plan offers a range of specialists available.
It may seem like a simple question, but whether your health insurance covers a specific medication can be complicated to answer. The first step is to check the preferred drug list (PDL) or “formulary,” the list of drugs that your health plan covers.
If the drug is on that list, that’s not the end of the story. Even covered medicines can be subject to rules such as prior authorization. That means you may have to get permission from your health plan before they’ll pay for the drug. If they deny your request, you can appeal. You might win, but there’s no guarantee.
Most health plans pay a separate company to manage their drug benefits. Those companies are called pharmacy benefit managers (PBMs). PBMs decide which drugs go on the PDL. Coverage decisions may be based on data about cost, effectiveness, available alternatives (if any), and generally accepted treatment guidelines.
PBMs also negotiate drug prices with drug makers and pharmacies, decide what patient copayments or other costs should apply, and set rules for access to specific drugs. PBMs sometimes manage specialty or mail-order pharmacies that health plan members are encouraged (or forced) to use.
If your health plan requires prior authorization for your medicine, you’ll have to get their permission before they’ll pay for it. The process to get that permission can be confusing. Usually, the HCP who prescribed the medicine will help. They’ll need to fill out a form and explain their reasoning for prescribing that medication for you. The health plan may follow up with the HCP for more information.
If the health plan denies your request, you usually have the right to appeal. The plan has to give you information about how to file an appeal. Again, your HCP or their office may help. The appeal may include more details from you and/or your HCP about why the medicine is necessary for you. Your HCP may need to show how the treatment fits within standard treatment guidelines, or why you need something different.
Sometimes you have the right to more than one level of appeal. You may be entitled to ask an external reviewer to look at your health plan’s decision and consider overturning it.
Plan-specific and state rules vary. Check your member handbook or ask the health plan customer service for step-by-step instructions for submitting a prior authorization request, and if necessary, an appeal. Your state’s insurance commission may help if you get stuck.
For covered medicines, you usually have to pay a copayment, a set fee every time you fill a prescription. The amount of that copayment can depend. For example, there are usually different copayments or other costs for drugs depending on how the plan categorizes them, called “tiers.” Tier 1 drugs might have the lowest copayments and fewest restrictions. Higher-tier drugs may cost you more and may come with more rules or hurdles.
Specific drugs may also be considered “preferred” or “non-preferred,” which may influence how much the drug costs you and how easy it is to get. The PDL should include these designations, if applicable.
In addition to copayments, other factors can affect your costs. If you have a deductible, you’ll have to pay the full drug cost until you meet the deductible.
Your health plan may also have a cap on the total you pay out of pocket each year, called an “out-of-pocket maximum.” If you reach that cap, you won’t have to pay any more copayments. But check the details — these caps may not kick in until you’ve paid many thousands of dollars.
When you’re looking at health insurance options, check the policy for covering new treatments when they become available. You can’t know for sure what future drugs your health plan will cover, but you can at least read their policy about how they decide which ones to cover. Ask the customer service team for that policy if you can’t find it easily.
You can also search health plan ratings to see how other people rate the plan, specifically on how easy it is to access needed care. Though it won’t predict what your specific experience will be, it can give you a sense of how other people feel about the plan’s coverage policies.Some medicines aren’t available through a typical retail or mail-order pharmacy. Medicines that aren’t used very often, need special handling, get injected or infused, or require special follow-up may only be available from a specialty pharmacy.
Specialty drugs may be more restricted and costly. You may have to follow specific rules or procedures to get them. Some asthma medications fall into this category.
Read your health plan documents for information about how to get specialty drugs if you need them. Your insurer may require you to use their preferred specialty pharmacy.
This educational resource was created with support from Amgen, a HealthyWomen Corporate Advisory Council member.