Tips for Navigating Your 2025 Benefits

I have worked in the insurance industry for 30 years now. I worked in marketing of health insurance plans, I wrote the welcome kits you get every year, created training materials, and worked with the sales force to create materials for plan members. Right now, I work for a prescription benefit manager. I’ve done prescription member services, processed prior authorizations, answered emails, and worked with client's concerns about plans being offered. From the perspective of working in the industry, I have some tips for you to consider when navigating your health benefits, especially now as it’s open enrollment for most of us.

Know your new coverage

Plans update in January/February and usually again in August/September. In fact, most people in the United States are in open enrollment right now, which is when you get to select your medical and prescription coverage for the coming year. The big update is upon your plan renewal, which, for most of us, is in January. You’re purchasing prescription insurance to help get you the best cost and to offset retail pricing, these things are updated regularly. Check your coverage now so you know what to expect come January.

Managing your coverage

Some medications and procedures require what's called a "prior authorization" to be covered. You will be given this information when you call to check your coverage. Typically someone in the doctor's office has to call and answer 4-6 clinical questions about your situation to get medications covered. Most plans prefer the generic alternatives to brand names, so check on that coverage as well. Procedure coverage is often more complicated than medication coverage and is something that will be navigated by your doctor’s office, but you should call your plan yourself so you have all the details. The more knowledgeable you are, the more you’ll be able to assist your doctor’s office, and the smoother the process will go.

NOTE: You may only do an authorization after your new plan has started, for most people this will be after January 1, 2025. Medication prior authorizations typically are valid for one year, it is your responsibility to know the information about your authorization and keep it update or renewed, after all, this is your medication and your treatment plan.

Know your plan limits

Getting a medication covered by a prior authorization does not mean your dose will necessarily be covered. Having a medication covered and having a specific therapy covered are two different things. As an example, acute migraine meds typically have dispensing limits, usually 9 pills or one pack every 30 days or 27 pills or three packs every 90 days. This follows FDA guidelines for safety, but most plans also offer what's called a patient level prior authorization. This allows you to request more based on your personal medical issues. Your doctor's office must call in and provide the clinical reasons for the higher dose. Dispensing limits may also apply to preventative medications and pain medications. The same goes for medical procedures. Some things are only covered so many times a year, this follows FDA guidelines for safety as well.

NOTE: This is not personal. In reality, no one at the insurance knows a thing about you and I can tell you from experience, we don't care about your situation. We care about helping you navigate your coverage. The questions for and about coverage must be answered by a medical professional. You may not provide any information, and this is often done as a safety net for you. I did prior authorizations for five years. I have horror stories about authorizations that came across my desk with doctors prescribing lethal doses, wrong meds for the diagnosis, and so on. Again, none of this is personal. It's clinical and it's set up to try and protect you. It's all very straight forward and it all depends 100% on the information from your doctor.

Follow the process

We all have preconceived notions about how things should work. You need to set these aside and speak with your plan. There is a process in place that must be followed. In my experience, if you don’t follow the process, you won’t be approved. If an authorization is required you have to do that first, you may want to appeal it if it's denied for some reason (and honestly most denials I see to this day are because the 4-6 clinical questions are answered wrong by the doctor's office) and then do a benefits appeal after that, if needed. You can't jump around and try to do a benefits appeal first, you must follow the process steps in place.

Is coverage medical or prescription?

Prescription coverage is for things you take yourself, typically called self-administered by the insurance industry. These are things you get from a pharmacy and keep in the house, dosing yourself. If you're getting treatment at the doctor's office, infusion clinic, or hospital, check your medical coverage. As a rule, treatments you give yourself are covered under prescription plans and treatments given to you in the office are covered under the medical plan. It’s important that you’re getting the correct coverage for the correct thing. Trying to get a medical procedure like an infusion of medication covered under your prescription plan won’t work and will delay your care. Call your insurance and be sure you have the correct information. Don’t assume your doctor knows your plan coverage. From experience I can almost guarantee they don’t. You need to get all the information yourself about how your coverage works and then partner with your doctor to navigate the plan.

Be nice

I can’t stress this enough; it is very important to be nice to the people on the phone who work for your insurance. These people are just doing their job either relaying coverage information to you or inputting the information provided by your doctor. They have no control over your coverage and no ability to change it. What they do is explain and review coverage information of your plan. Representatives are much more likely to "go to bat for you" and try to guide you through the process when you're nice. When you get nasty with the person on the phone, they're going to tell you something like "follow the directions on the back of page one" rather than trying to walk you through the process and maybe give you insider information like I'm doing right now

The internet is a wonderful tool

Medical and prescription insurance is exactly like home and auto insurance; it’s designed to off-set costs. It’s not designed to provide anything for free. I recommend always hunting for coupons and manufacturer programs to help offset the cost of medications. You’ll be amazed by what is available and what you may be able to get at no cost yourself.