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Health Benefits is a type of insurance that helps to cover the cost of medical services and supplies that aren’t usually covered under universal provincial medicare. Benefit packages vary, even within the same company, so it is good to determine AHEAD of purchasing something if you will be covered for it, how you claim the cost, and how much of the cost will be covered.
There are a variety of items that might be covered as part of a benefits package:
The coverage of most services are clearly outlined in your policy booklet. You can also call the insurer or check your profile on-line to verify the information. The coverage of prescription drugs, equipment, and assistive devices may not be as clear. For these items, it is best to contact the insurer ahead of time or have the provider (e.g. a pharmacy or health product store) check for you.
If you are calling your insurer to check on coverage of a prescription drug, product or device, you will need the following information:
When you call the insurer, ask the following questions:
Some drugs, products or devices need to be approved by the insurer BEFORE they can be paid for. This is called “prior authorization” or “special authorization”. Many plans use this to ensure the drug or product you were prescribed is appropriate and meets their guidelines for payment.
If you are told by the insurer that a Prior Authorization is needed, there are two way this is done:
The most common delays experienced with Prior Authorization are due to errors or omissions by the prescriber when completing forms. It is helpful to contact the insurer after the form is submitted to make sure the form was received and was complete. On average, the prior authorization review takes 3-10 business days.
If you are told by the insurer/pharmacist/provider that a drug or product isn’t covered by your plan, check the following information to determine your next steps:
If you discover that a drug or product is NOT included in your plan, and it is NOT a “non-benefit”, you may have some options for appeal:
If the drug/product/device is listed on your plan and approved for coverage, how your plan pays for it depends on how your plan is set up:
How much your plan pays for a drug, product, or device depends on your plan. If you have to pay something, these are the types of fees that are charged and leftover costs that may apply. Understanding what you have to pay can help you better prepare and anticipate if you need help with the cost of your medication and supplies.
Deductible – an amount you are required to pay before the insurer will provide payment on any benefits; usually this is a set amount you must pay on any drugs or products first at the beginning of the year; some plans use this feature, some don’t.
Co-payment – a portion (%) of the cost OR a set dollar amount that you pay each time you pick up the drug or product.
Dispensing Fee – an amount you pay to the pharmacy/provider for the service if preparing and dispensing the drug/product; a dispensing fee can range from $7-15 dollars.
Generic Pricing – some plans are set up to default to the lowest price available for a drug or product; usually this applies to a drug/product where there is both a brand and a “generic” version available; even if you purchase the brand, the plan will only pay the generic price so you are left facing the difference in cost; most pharmacies will inform you ahead of filling a prescription that the plan only pays the generic price; if you are unsure…ask BEFORE you fill the prescription.
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