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How Do I Get The Most From My Healthcare Benefits and Have A Successful Healthcare Experience?

 Preparing for an Office Visit
  • Find a primary care physician you can trust before any health concerns arise.
  • Make a list of how, what, when and where your symptoms began.
  • Make a list of current medications you are on.
  • Make sure you have up to date documentation – medical ID card with your carrier name, policy number, claims address, copay or deductible amounts and your member ID (remember you can get temporary cards on line at your carrier’s website).
  • If you are there for a routine physical exam, remind your physician to file it as a routine preventive care coding.
  • Contact your insurance company if you believe your claim was paid incorrectly.
  • If you are concerned about your diagnosis or not sure about a prescription, check with your employer to see if you have an advocacy program available to help answer questions and make sound decisions.

Finally, when communicating with your provider or insurance carrier, make sure to keep a record of the communication, including date/time of the conversation and the name of the person you spoke to. Get a reference number if available. 

Time and Cost Savings

  • If you are suffering from minor illnesses or injuries, go to a convenience clinic. These are clinics that are located in your local pharmacies such as CVS or Walgreens in Florida. These clinics will charge you an office-visit copay and will have your prescription ready shortly after you check out with the provider. This will not only save you money, but it will also save you time. Urgent care and emergency room visits are very expensive, and wait times are enormous.
  • Check with your local pharmacy providers to see if they have free or low-cost prescriptions available. In Florida, Publix provides most oral antibiotics free of charge as well as some maintenance medications.
  • Some pharmacies will provide you with a 90 day supply of a drug right there at the location and charge you a lower fee than what you would pay under your health plan. Remember, you don’t have to use your insurance program if the pharmacy costs are less. Ask the pharmacist if it is better to use or not to use your insurance.
  • There are also many pharmacy discount programs available.

 What Does It All Mean?

  •  What is a deductible? As you incur expenses, the insurance company keeps track of them as they accumulate towards your deductible. Typically this is for major services, such as inpatient and outpatient hospital services, home health care, major diagnostics etc.
  • Where does the Copayment come in to play? With most major medical plans in the market today, you will have a specified copayment for office visits, lab and x-ray, pharmacy, emergency room and some urgent care services. When the copayment is listed, that is all you pay and your deductible does not apply.
  • What is the maximum out of pocket? The total amount a covered person must pay before his or her benefits are covered at 100%.The out of pocket maximum does include deductibles and copays.
  • What is a Section 125 Plan? Section 125 of the IRS code allows you to pay your share of the health, dental and certain other health premiums with “pre-tax” income. That means your employer takes the premium out of your pay check before you pay taxes on it. You save money because you do not pay taxes on the money used to pay for the insurance.
  • What is a “Qualifying Event”? Under the IRS Code Section 125, you cannot make changes to your elections unless you have a qualifying event such as a birth, marriage, divorce, death or some other event that would allow you to make changes during the year. If you do not have a qualifying event occur, you can only make changes at annual open enrollment.