What to do now that you have health insurance

First published in Landings, June, 2015.

We hope last month’s article encouraged you to select your primary care physician; perhaps you even made an appointment. If you have visited a doctor, you have probably received an Explanation of Benefits (EOB) from your insurance company. An EOB is not a bill, rather it is an explanation of charges and who is responsible for payment. After you visit the doctor, they will bill the insurance company. The EOB shows you what your doctor’s visit cost, how much of that cost your insurance company covered and what is left for you to pay. Your doctor’s office will send you a bill for the charges you are responsible for separately.

Not all EOBs look the same, but they all have the same information, including:Service description – what kind of care you received

  • Provider charges – how much your visit cost
  • Allowed charges – the amount your provider will be reimbursed
  • Paid by insurer – the amount your insurance plan will cover
  • Payee – The person who will get reimbursed if the claim is overpaid (may be you or your provider)
  • What you owe – the amount you owe your provider

 

The remark code is a code that explains more about the costs. The code should be explained under the list of charges or on the back of your EOB. You may also notice information on how much you have paid out-of-pocket and how much has been applied to your deductible. If any EOB_1of the information on your EOB is incorrect, or you feel a service wasn’t covered at the correct rate, you can appeal it. Your EOB should come with information on how to file an appeal or grievance – it may be printed on the back of your EOB. If you believe a service should have been covered and wasn’t, call your insurance company. Its phone number should be near the logo or on the back of your EOB.

Your insurance plan does more than help pay for doctors’ visits: it also helps cover the cost of prescription medicines. Each plan has an approved list of medicines that your insurance company will cover at three different levels. This list is called a formulary and can be found on your insurance company’s Web site or you can call your insurance company and request it.

EOB_2A formulary will list both generic and brand-name drugs that your plan covers. Generic drugs are considered Tier 1 drugs and will cost you the least. Tier 2 drugs cost more and consist of preferred, brand-name drugs; Tier 3 is made up of non-preferred, brand-name drugs which will cost more than the other two tiers of drugs. Some plans also have Tier 4 for specialty drugs. If your doctor prescribes you a medicine, ask if there is a generic you can take that works as well as the brand-name so you can save money.

Formularies have many, many pages of drugs listed. If you have a digital copy of your formulary on your computer, you can quickly find a drug by hitting the “control” and “f” keys at the same time. This will bring up a search menu so you can type in the drug you are looking for. You can also call your insurance company and ask if your plan covers certain drugs.