These questions are pulled from various sources – Web sources, forms I have seen or used, materials I developed (long ago) – for families to use. to ask about current coverage (or to compare plans when looking for a new plan) (some relate to services for adult family members – who need care too…)
Does my plan cover these services?  And for each (since it’s all about $$) – Is there an annual deductable?  What are co-pays?  Is there an annual upper payment limit/cap or limit/cap on number of visits?  What are lifetime limits/caps?.  Is there an annual limit for out-of-pocket expenses?  What are the differences in cost between using a provider who is part of the plan and one that is not part of the plan?

  • Physical examinations and health screenings.
  • Care by specialists.
  • Hospitalization
  • Emergency care.
  • Prescription drugs (see more detailed questions below).
  • Vision care.
  • Dental services.
  • Care and counseling for mental health.
  • Services for drug and alcohol abuse.
  • Obstetrical-gynecological care and family planning services.
  • Ongoing care for chronic (long-term) diseases, conditions, or disabilities.
  • Physical therapy and other rehabilitative care.
  • Home health, nursing home, and hospice care.
  • Chiropractic or alternative health care, such as acupuncture.
  • Experimental treatments.
  • What preventive care is offered, such as shots for children?
  • What health screenings are covered, such as breast exams and Pap smears for women?
  • If the plan does not have a certain type of subspecialist in its network who is trained in the care of children, can I see an out of network pediatric specialist at no additional cost?

What is the plan’s definition of medically necessary?  (How/who determines medical necessity of services?) Are benefits, costs, etc different if traveling – out of state. Here are questions to ask to better understand a health insurance plan’s pharmacy benefit:

  • Does the plan require that doctor to choose drugs from a formulary, or list of covered medicines?
  • If so, are the prescriptions that my family needs on the plan’s formulary? If we need a medicine that is not on the formulary, will we have to pay for it myself, or will the plan reconsider its decision based on an appeal?
  • What is the process for pursuing an appeal?
  • How much are co-payments, or What do I owe the pharmacy when I get a prescription?
  • Does the plan use a prescription mail order services?  Is there a penalty if I don’t want to use the mail order service? Will the plan require that I use it, or can I choose to get medicines at a local pharmacy?
  • Is there a limit to out-of-pocket expenses? Does it include the amount I pay for my medications?
  • Is there a cap (limit) on my total benefits? Is it possible that I could use up all my benefits and have to pay full price myself for anything else I need?
  • If there is a less expensive medicine than the one my doctor prescribes, will the health plan require that the cheaper one is used first? (This is called step therapy.)
  • Does the health plan ever call doctors to ask them to switch patients to a different, cheaper drug? (This is called therapeutic substitution.)
  • Does the health plan require approval for certain medicines before it will pay for them? If so, how is this prior authorization obtained?


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