Now that you’ve enrolled, it’s time to focus on the road ahead. And there are things you need to do now to use your benefits successfully when they take effect.
Here’s your to-do list:
Know How Your Prescription Drug Plan Works
Your prescription drug coverage is provided through your medical insurance carrier’s pharmacy benefit manager, who sets the rules for how medications are covered. Don’t be caught by surprise! Visit your carrier’s website for information about your medications. And, check out the Prescription Drug Transition Worksheet (PDF) for tips and questions you may need to ask your carrier.
Check the Formulary
A formulary is a list of generic and brand name drugs that are approved by the Food and Drug Administration (FDA) and are covered under your prescription drug plan. Check with your carrier to make sure your drug is listed on the formulary before you fill it. If it isn’t, you’ll pay more.
Generic drugs meet the same standards as brand name drugs, but they typically cost less. And, because brand name drugs can be expensive, some carriers don’t cover them at all if a generic is available. Ask your doctor if a generic drug is available for you.
Mail-order service can save you a trip to the pharmacy and may reduce your costs. To set up mail order with a new medical insurance carrier, you’ll likely need a new 90-day prescription from your doctor. Because mail-order can take a few weeks to establish, it’s a good idea to ask your doctor for a 30-day prescription to fill at a retail pharmacy in the meantime.
Track your to-dos and get organized! Print the Prescription Drug Transition Worksheet (PDF).
“Transition of Care” Setup
Are you or a covered family member pregnant? Will you or your covered family member continue needing treatment for an ongoing medical condition?
If you will have a new medical insurance carrier and you answered “yes” to either question, you may be able to temporarily continue that care with your current provider once your new medical coverage begins. This is true even if your provider isn’t in the new insurance carrier’s network.
If you think this applies to you, call customer service at your new medical insurance carrier as soon as possible to ask for help with “transition of care.”
Give your new insurance carrier information about your treatment and the providers you use today.
Will you have a new dental plan? Will you or your child(ren) continue receiving ongoing orthodontic treatment? Call customer service at your new dental insurance carrier as soon as possible to ask for help with “transition of care.”
Track your to-dos and get organized! Print the Transition of Care Worksheet (PDF).
Avoid Unexpected Out-of-Network Costs
It’s very important to know whether your doctor participates in your medical insurance carrier’s network.
You Could Pay a Lot More for Out-of-Network Care
Your medical insurance carrier could pay a much lower benefit if you see an out-of-network doctor—leaving you to pay the rest.
For instance, you will pay more through a higher out-of-network deductible and higher coinsurance. You'll also have to pay the entire amount of the out-of-network provider's charge that exceeds the maximum allowed amount, even after you've reached your annual out-of-network out-of-pocket maximum.
Each medical insurance carrier can determine its maximum allowed amounts for out-of-network providers. For example, among other ways, carriers may use what's considered "reasonable and customary" and/or a Medicare-based calculation to determine the maximum allowed amount.
For example, let's say you will have an out-of-network surgery that costs $5,000 and you will pay 45% coinsurance. The maximum allowed amounts could be different across carriers:
- If one carrier has a maximum allowed amount of $2,000, you would owe 45% of $2,000 and 100% of the remaining $3,000, for a total of $3,900.
- If a second carrier has a maximum allowed amount of $3,000, you would owe 45% of $3,000 and 100% of the remaining $2,000, for a total of $3,350.
Take These Steps to Protect Yourself
If you didn’t check your doctor’s status before you enrolled or you want to look up a different doctor, do it now—before making an appointment with that doctor.
You can check the provider directory through Your Total Rewards at http://digital.alight.com/equitable/ or your medical insurance carrier’s website.
Important! Do not rely on your provider’s office to know the carriers’ network(s). If you have any uncertainty (for instance, covering out-of-area dependents) or you need the network name, call the insurance carrier.
Even if you’re keeping the same insurance carrier, the provider network could be different. Always check the provider directories on the carrier preview sites before making a decision.
If your doctor is out-of-network and you still want to see him or her, check the cost with your doctor before you get care. Then ask your doctor to confirm the portion that will be covered by your medical insurance carrier and the portion for which you’ll be responsible. That way you’ll be prepared for any potentially significant costs.
When to Expect New Cards
You’ll receive a new ID card when you enroll for the first time or change insurance carriers or coverage levels. You'll use your ID card for medical and prescription drug needs.
Note: Many dental insurance carriers also issue ID cards. If you receive one, simply present it when you get dental care during the new plan year.
For questions about ID cards, contact the insurance carrier. If you need an ID card immediately, go to your insurance carrier’s website, register online, and print a temporary ID card.
Want to Print?
Track your to-dos and get organized! Print these worksheets and get a step-by-step guide to what to do and what to ask as you get ready to use your new coverage.
Prescription Drug Transition Worksheet (PDF)
Transition of Care Worksheet (PDF)