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How to See if Your Healthcare Plan Covers Your Prescriptions

There are many reasons why you’d want to look out if your insurance plan covers your medication prescription. If you’re looking around for a new insurance plan and it’s important to find out if your current medications are covered.

Maybe your healthcare professional just prescribed an alternative medication and you would like to see it before you choose the insurance policy. While this information is searchable, it does require some skill to find it. We will help you through this article.

Whenever doctors prescribe an expensive form of medication, the first thought in your mind is if your insurance plan covers the cost. Or even you would like to understand what tier a drug is in, or whether it is a preferred or non-preferred brand.

You have different options for getting this information. We’ll assist you in understanding where to look for it.

 

Does my new insurance plan cover my prescription?

Follow the following steps to figure out the prescriptions covered under your new Marketplace plan:

  1. Visit your insurer’s website to review an inventory of prescriptions your plan covers
  2. See your Summary of advantages and Coverage, which you’ll get directly from your insurance firm, or by employing a link that appears within the detailed description of your plan in your Marketplace account.
  3. Call your insurer to inquire what’s covered. Have your plan information available. It all available on your insurance card, the insurer’s website, or the detailed plan description in your Marketplace account.
  4. Check out any details your insurance firm sent you for the coverage you have got

 

Summary of Benefits and Coverage (SBC):

This document may be a summary of what the health plan covers. While the formulary doesn’t actually tell you ways much different tiered drugs will cost you, the SBC will outline what quantity your copay is for every tier.

When you’re buying healthcare plans or determining whether to stick or to not stick with your current one, use the formulary and SBC to search out whether a selected medication is covered. Based on an example of a tier 3 medication such as insulin SBC, is to be considered a “non-preferred brand”, meaning that you simply need to pay 40% of the drug’s cost. When choosing a health plan option, it’s important to get one with a cheap premium provider (the amount you buy insurance every month) and also consider which plan has the simplest coverage and possibly the lowest out-of-pocket expenses for your medical needs.

During open enrollment periods (the time people are buying new plans, insurance companies are required to form list of medicines and SBCs available. It’s your right to request a list of medicines for an idea you’re buying.

 

Can I attend my regular pharmacy to urge my medication?

Just like different health plans cover different medications, different health plans allow you to buy your medications from different pharmacies (called “in-network pharmacies”). Call your insurance firm or visit their website to seek out whether your regular pharmacy is in-network under your new plan and, if not, what pharmacies in your area are in-network. You’ll also learn if you’ll get your prescription delivered within the mail.

If you’ve got additional questions, call 800.858.1772 to get the required information.

 

Cash in on savings on prescriptions

Consultants look at drug costs to find savings

ClaimLinx analyzes each company’s drug usage to find cost-cutting measures. First, it saves employers money. Most importantly, it helps workers be able to afford the medications they need consistently.

Why ClaimLinx Focuses on Rx Costs

Medications are one of the most important tools people have to maintain their health. However, prescription drug costs keep rising each year. By the end of last year, more than 20 generic drugs had a price increase of 29.4%. Also last year, the cost of more than 1,200 drugs rose by 5-6%. It’s a trend that has so far continued into 2021.

What research has shown is that when medication are expensive, people do not fill the prescription or do not do so consistently. In fact, between 20-30% of prescriptions are never filled because of costs. Up to 50% of medications for chronic illnesses are not taken consistently because they’re too expensive. That all adds up to a real impact on members’ health.

That’s why ClaimLinx prioritizes savings on prescriptions. We know it’s important for employees to take their medications consistently to be productive at work. We also know employers don’t have endless funds for drug coverage. To help with that, we focus on finding a balance between the two.

How ClamLinx Saves on Prescriptions

Our consultants get real-time data on prescription usage through our partner pharmacy benefit managers (PBM). Unlike with a standard insurance plan, ClaimLinx sets up a prescription drug plan with a PBM we trust. That allows our consultants to see which medications workers need and how much they cost. From there, our service team has many methods they can use to cut costs on prescriptions. That saves money for both the employer and the employee.

Enrolling in drug coupon programs

One of the ways ClaimLinx cuts costs on prescriptions is by researching drug programs and coupons for medications. These are many coupon programs through the manufacturers and through different pharmacies. There are also cost sharing programs available for those with financial need. We seek these out because they help the employer. But more importantly, they help the employee afford the drugs they need to stay healthy.

Moving members to a new plan

Another cost-saving measure is to move certain members on the plan to new health insurance plans with more prescription coverage or discounts. For some members, it makes more sense for them to be on a more comprehensive plan. The plan may be higher cost, but it will save in the long run if the drugs are expensive. Our agents are seasoned in taking this into account when finding members the plan that’s going to work best.

Finding generic version of drugs

As a part of ClaimLinx’s overall solution, we place an emphasis on educating members on costs so they can be good healthcare consumers. To help with that, we recommend members have an open dialogue with their providers about their prescriptions. We tell members to ask their doctors if they have chosen a brand name drug why that is. Is there an alternative that can achieve the same results. We also help workers research generic versions of brand name drugs, if they are available. Sometimes providers are unaware of the costs of prescriptions so it’s important to talk with them when the drugs are expensive.

Shows Schedule of Benefits at work

ClaimLinx customizes every client’s Schedule of Benefits

Every ClaimLinx client receives a custom schedule of benefits. ClaimLinx experts design it to fit the company’s needs, usage and budget. That is flexibility in plan design you can’t find anywhere else.

What is a Schedule of Benefits (SOB)

A Schedule of Benefits, or SOB, is a list of the services a health plan covers. It’s a record of the fees a member will be charged for certain standard services. Members receive an SOB at the beginning of their policy. It shows what treatments will be covered and at what dollar amount or percentage they will be covered. That way members know about how much the visit will cost before they arrive.

How ClaimLinx customizes SOBs

For any company that chooses the ClaimLinx Simple Option Solution, one of our expert consultants creates a custom SOB. For new clients, we typically base the first SOB on the company’s previous plan. That way there’s no disruption in coverage or benefits. It’s a seamless transition from a client’s old plan to the ClaimLinx Solution.

After the client has made the transition, our consultants look at usage throughout the year. That’s because ClamLinx is a third-party administrator. That means we process the claims in-house. This allows us to see how members are using the plan in real time. Using that information, our consultants can make adjustments to help the plan work better. With regular group insurance, employers never see how much their workers are using the plan. But with ClaimLinx, we’re able to tell you what services members are using. That way, we can tell you what changes to make to either cut costs or improve benefits.

Because the plan is not through a big insurance company, it does not have to fit a certain mold. We can change how much a member pays for specific services without having to change the entire plan. Also because this is all done in-house, it can be done quickly, even before renewal.  You will not find more flexibility in a health plan.

Why custom benefits are better

Being able to customize the health plan helps companies make sure budget and and benefit goals are in sync. Because our consultants can see actual plan usage, they can tell clients where they may be able to adjust the plan to lower costs. For example, we often see companies that have a lot of emergency room claims, which tend to be very expensive. In this scenario, we recommend raising the cost of those claims to the employee and lowering the cost of urgent care visits. That way, members are being taught and encouraged to find lower costs alternatives to going straight to the emergency room.

Custom benefits are also great because they can be adjusted to reflect your company’s specific needs and/or demographics. For example, a company with a lot of families may want to make sure the cost of office visits stays low to ensure children and parents can afford preventative care visits. Or, alternatively, a company with a lot of older employees may want to cover more testing procedures or prescription medications to help works afford to manage any chronic conditions they may have.

There is so much our consultants can do to make sure the health plan is working for everyone. It doesn’t have to break the bank. And at the end of the day, having healthy employees improves productivity for the company. That’s happy for everyone.

Talk

When was the last time your health insurance agent took a look at your company’s plan usage? How about when did he or she last bring you a DECREASE in your overall plan costs?

We’re willing to bet that’s never happened with your traditional insurance broker.

That’s something only a true consultant like ClaimLinx can do.

Not only that, ClaimLinx sits down with you to find out what benefits are important you and your employees. We take a look at the age, health and needs of your employees because we know every company is different. Some companies may have employees with low cost prescriptions. Others may want to prioritize keeping premiums as low as possible for workers.

We listen to what you need and then show you how to make it happen. Best of all, you know you’re getting a great deal on all of it.

Related Post: See ClaimLinx’s Complimentary Elite Services for Clients

What we offer our clients:

  • Plan analysis from a consultant when making benefit decisions
  • Personalized service from a team with experience
  • A customized benefit plan just for your company
  • Annual savings on a comparable plan

Our highest priority is to make sure our clients receive the employer-paid benefits they want at the very best price possible.

How we do this:

We do this through our unique ClaimLinx Simple Option Solution, an innovative strategy for purchasing benefits that combines a high-deductible plan from a major insurance carrier with a self-funded medical expense reimbursement plan (MERP). That way you get the best of both.

The high deductible plan provides a comprehensive physicians network and a stop-loss in case an employee has high medical costs. The company MERP provides the benefits people are used to, including a lower deductible and copays for regular office visits and procedures. That way you’re always only paying for the services your employees are actually using.

Related Post: What a Full-Service Insurance Agency Can Do for You

But it’s not just about getting health insurance benefits at a great price. It’s also about having a resource and true ally in an ever-changing industry. With our solution, clients have the opportunity to make employer-paid benefit decisions based on employee usage and company priorities. We aim to finally close the gap between your ideal benefits package and what your budget will allow. ClaimLinx helps both business owners and employees save money on health insurance costs.

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1095-A

WHAT TO DO WITH FORM 1095-A

In case, you or anyone in your family has decided to get insurance then you need to fill out Form 1095-A. You must get them to initiate the complete procedure of getting insurance. Form 1095-A is available at your Healthcare.gov account for all users.

 

What is Form 1095-A comprised of

Your 1095-A provided information about Marketplace plans anyone in your family has had including:

  1. Any paid Premiums
  2. Utilized Premium Tax Credits
  3. Your SLCSP (Second-lowest-cost silver plan)

You’ll use information from your 1095-A to fill out Form 8962, Premium Tax credit. This is often how you’ll “reconcile” — determine if there’s any difference between the premium tax credit you used and therefore the amount you qualify for and if you didn’t take any advance payments for your premium tax credit despite having Marketplace coverage.

 

 

Important Facts to Remember:

  1. Form 1095-A shall provide information about your family’s marketplace plans in 2020.
  2. It is important to keep this Form readily available and store it where you keep your tax information and other details.
  3. Keep in mind that the IRS does not provide Form 1095-A, you can get it from the marketplace.

 

How to find your 1095-A online

Your 1095-A is available in your HealthCare.gov account

  1. Below “Your Existing Applications,” go to our 2020 application.
  2. Choose “Tax Forms” from the left-hand side menu
  3. Save all the 1095-A files

In case you couldn’t find 1095-A in your account, you can reach out to the service center for any inquiries.

 

What to do if your information on Form 1095-A is wrong

It is very important to carefully analyze information filled out on your Form 1095-A in order to rule out any discrepancies.

Read the instructions at the back end carefully and make sure the information is accurate. If anything about your coverage or household is wrong, contact the Marketplace call center.  Also, it is very important to make sure that your SLCSP information is mentioned correctly.

 

How to know if your SLCSP information is correct

You can easily check your SLCSP information by following these steps:

You’ll notice Column B in Part 3 titled “Monthly SLCSP”. This would include facts and figures for all of your family members and their marketplace plans.

 

You’ll know that the SLCSP premium information is wrong if:

  1. There is a blank portion in Column B, Part III, or if it has a “0” during the months where your family members had the marketplace plan.
  2. If there were significant changes that weren’t communicated to the marketplace, i.e. getting divorced or married, losing a family member or having a baby, etc.

 

Use the knowledge from your 1095-A to “reconcile”

Once you’ve got an accurate 1095-A and your SLCSP premium, you’re able to fill out Form 8962 easily and reconcile your premium tax credit.