It's that time of year and for many of us, that means that mistletoe won't be the only thing hanging over our heads. Some of us have the daunting task of finding health insurance plans that fit both our budget and our medical needs.
The key to picking the best insurance plan is to outline the costs you expect to pay (routine prescriptions, check-ups), analyze the costs you could incur (urgent care/ER/hospital visits) and price out various scenarios.
Compile Your Routine Annual Costs
Start with making a list of what a routine year looks like for you. What prescriptions do you fill on a routinely basis and how often? Will you possibly need durable medical equipment (DME) coverage for a pump or CGM? How frequently do you go to the primary care doctor or specialist? Do you have any surgeries coming up? These are factors you can price out to get a base analysis of what you will definitely be paying.
The next step requires a mixture of foresight and luck. You will need to consider other variable costs such as ER visits, urgent care, or hospital stays. This can drastically change your total costs over the year and can make certain insurance plans better options if the care ends up being necessary.
Gather Details from Each Insurance Plan
At minimum, you will want to find out each plan's: deductible, out-of-pocket maximum, and costs for primary care visits, specialist visits, emergency care, urgent care, hospital stays and DME coverage. You will also want to check which tiers your prescriptions will fall under and the cost of each tier. If you are ordering a pump or CGM, you will need to understand if those are covered under pharmacy benefits or DME coverage.
I get my insurance through my work and we deal with United Healthcare. The summary of benefits and coverage (SBC) contained most of the data I needed, although I had to visit their website to search through the prescription tiers to find where Jasper's insulin and test strips landed (the link was listed on the SBC). I actually had to call them to find out of the pump or CGM was covered as DME or pharmacy benefits.
In a routine year, Jasper is guaranteed to at least incur these main costs:
- Prescriptions for:
- Insulin (2x)*
- Test strips (4x)*
- Omnipod pods
- Dexcom sensors and transmitters
- 1 primary care visit (well-check + flu shot)
- 4 specialist visits (quarterly endocrinologist visits)
*To note, we use a 3-month mail order pharmacy to get Jasper's supplies, which is why his prescription order numbers look low. We also only order insulin twice a year since he switched to a pump and we get extra vials now. I've also noticed some of his other prescriptions, such as ketone urine strips, alchohol swabs, and glucagon don't fall under our prescription tier costs, but their cost is trivial in comparison to his other care so I disregard them in my analysis.
At first glance, plan B may have seemed like a better option. With a cheaper monthly premium and a lower deductible, it may be more appealing at first glance, but the DME coverage for the pump and CGM fails us at 30% coinsurance and a $7500 out-of-pocket maximum. In reality, in the above scenarios, the plan would cost us an additional $3200 or so next year. Additionally, since plan A also has an out-of-pocket maximum of $7000, even if we added a handful of emergency care and urgent care visits into the cost, we would still max out at $9,628 (the costs of the monthly premiums + $7000 max) which still doesn't touch the cost of plan B. For these reasons, we would opt for Plan A.