A common means of covering health-related costs, including medication costs, is private health insurance. Private health insurance is most commonly funded through contributions from employees and employers or purchased by an individual.
Private health insurance companies offer a wide variety of plans with various forms of coverage, rules about in-network and out-of-network doctors, and co-payment stipulations. Depending on the plan, your doctor visit costs could be significantly cheaper for an in-network doctor than for an out-of-network one. Private health insurance plans also usually include both pharmacy and medical benefits. It’s crucial that you understand your coverage in both of these areas.
For some more expensive medical procedures and medicines, many private health insurance plans may pay for only a portion of treatment. This can be frustrating and a financial burden, but fortunately there are many ways to supplement this coverage, through government assistance, patient assistance programs (PAPs) and private organizations.
If you need to purchase a private health insurance plan, make sure to inquire about coverage for costs associated with RA treatment, such as medications, doctor visits, and co-payment. If you are considering a health maintenance organization (HMO), preferred provider organization (PPO), or point-of-service (POS) plan, make sure to verify that your current doctor is in the plan’s network, since that may affect the costs associated with treatment. If he or she is not, you’ll need to decide if you are willing to switch to a new doctor. Also, be sure that the plan allows for access to specialists, specifically rheumatologists in the case of an RA patient.
An HMO plan typically will require that you receive all your medical care in-network – you select a primary care physician, who refers you to in-network specialists. PPO plans typically do offer some reimbursement for out-of-network doctors, and are appealing in that they typically don’t require primary care physician approval for out-of-network specialist visits. POS plans typically function similarly to PPO plans by giving you the option of seeing out-of-network specialists, but with POS plans these visits typically require a referral from your primary care physician.
There are a large number of treatment options available to patients with RA. These treatments vary greatly, and as such it is important to understand the way that your therapy may be classified by your health insurance provider. Typically, treatment options are classified as either a pharmacy benefit or a medical benefit. These classifications can affect the way the treatment is reimbursed to your physician, as well as how much you have to pay for the therapy.
Pharmacy Benefits
Therapies that do not require administration by a healthcare professional are typically included in the pharmacy benefit. These usually include both oral and self-injectable medications. Products covered under the pharmacy benefit are usually subject to a co-payment.
Medical Benefits
Therapies that may require administration by a healthcare professional, including your physician or nurse, or require supervision for administration, are typically classified as a medical benefit. Products covered under the medical benefit may be subject to co-insurance.
Navigating the world of private insurance can be exhausting and overwhelming – sometimes it’s hard to know where to start. Fortunately there are excellent resources available to help you with the process.
