Using your health insurance is easy if you know:

  • What services are covered
  • How to use your plan for different kinds of care
  • Where you can receive care

What services are covered?

Most plans must provide 10 essential health benefits, regardless of who is providing your insurance

  1. Preventive services (such as immunizations and mammograms) and management of chronic diseases such as diabetes
  2. Emergency services
  3. Hospitalization
  4. Laboratory tests
  5. Maternity and newborn care
  6. Mental health and substance-abuse treatment
  7. Outpatient care (doctors and other services you receive outside of a hospital)
  8. Pediatric services, including dental and vision care
  9. Prescription drugs
  10. Rehabilitation services

Your access to doctors, hospitals, and other health care providers, and how much you'll pay out of your own pocket for each service will be different for each type of plan.

For more detail on what is covered, check your plan's Summary of Benefits and Coverage (SBC). All private insurance plans are required to explain your plan type, coverage period, what this plan covers, and what it costs. Understand what is in your SBC to get the most out of your coverage!

What do all these terms and letters mean?

Use the glossary

How do I use my plan for different kinds of care?

  • Most doctors take Medicare; not all doctors take Medicaid
  • Present your card at each visit
  • You can go to doctors and hospitals that are in-network
  • If you go to a doctor or hospital out-of-network, it will cost more, and you may have to file your own claims
  • Present your card at each visit
  • You must see a doctor in your network
  • You must have a primary care physician (PCP)
  • If you need to see a specialist, your PCP must refer you
  • Present your card at each visit
  • You must have a primary care physician (PCP), but you don't need a referral to see a specialist
  • You can go to doctors and hospitals that are in-network
  • If you go to a doctor or hospital that is out-of-network, it will cost more, and you may have to file your own claims
  • Present your card at each visit
  • After your doctor has prescribed a medicine for you, ask your pharmacist if it's covered by your plan
  • Not all medicines are covered. Each plan has a different list of medicines that are covered, called a drug list or formulary
    • Most formularies are split into 4 groups (called tiers) based on how much you will have to pay out-of-pocket when you fill the prescription
Tier Description Cost
1 Generic versions of medicines that cost less $$$$
2 Brand name medicines selected by your insurance and their network physicians (called preferred) $$$$
3 Other brand name medicines (called non-preferred) $$$$
4 (Specialty) Medicines usually prescribed by a specialist for certain health conditions $$$$

Some plans may be different, so check with your plan to see what medicines are covered and what they might cost.

  • If there are steps you must take for your medicine to be covered by your plan (prior-authorization, step therapy, quantity limit, etc), talk to your doctor about how you can get access. Your doctor may need to submit a special request to your insurance company for coverage if they believe it is medically necessary
  • Ask your doctor and your pharmacist if there is a generic version of your prescription or a cheaper alternative. Doing this may cost you less money
    • If you use a mail-order pharmacy, contact them by phone to ask about replacing brand name medicine with generics
  • You may have a separate insurance card for prescriptions. Have your card with you when get your prescription filled or when you are on the phone with your mail-order pharmacy
  • Some plans may have a separate deductible that applies to prescription medicines. You would need to meet this deductible before you could start paying the copay or coinsurance amount for your specific medicine.
  • Some drug companies help patients with the costs of their medicines. These programs are subject to terms and conditions, and not all patients will be eligible for savings
  • You may want to check if the drug company that makes your medicine offers a cost-savings program for which you are eligible. Because these programs can be discontinued or your eligibility can change, you should not rely on them when selecting health insurance coverage
  • Savings offers on certain Merck medicines are available for eligible patients; please see the terms and conditions of the offer for eligibility requirements
  • If you do not have prescription-drug coverage and cannot afford your medicines, you may be eligible for free Merck medicines through the Merck Patient Assistance Program. Get the facts about this and other programs from Merck. Visit www.MerckHelps.com
  • Sometimes you may need to see a special doctor to receive care (for example, a cardiologist for heart problems)
  • Depending on what type of plan you have, you may need a referral from your PCP in order for your health insurance to cover the cost
  • See the list above or view the chart below to learn which plans require your PCP to write a referral and which let you make the choice yourself

Learn how to use health insurance based on your plan types

Health Maintenance Organization (HMOs)

Need PCP and referrals?

Need preauthorization for some services?

If needed, often handled by PCP

Helps pay for Out-of-Network Care?

File Own Claim Paperwork?

Exclusive Provider Organizations (EPOs)

Need PCP and referrals?

Need preauthorization for some services?

Helps pay for Out-of-Network Care?

File Own Claim Paperwork?

Point-of-Service Plans (POS)

Need PCP and referrals?

May require

Need preauthorization for some services?

If needed, often handled by PCP. Out-of-Network care may be different

Helps pay for Out-of-Network Care?

Yes, but some may require referrals

File Own Claim Paperwork?

May be required for out-of-network care

Preferred Provider Organizations (PPOs)

Need PCP and referrals?

Need preauthorization for some services?

Varies. Check with your plan

Helps pay for Out-of-Network Care?

File Own Claim Paperwork?

May be required for out-of-network care

High Deductible Health Plan (HDHP)

Need PCP and referrals?

Need preauthorization for some services?

Helps pay for Out-of-Network Care?

Varies

File Own Claim Paperwork?

May be required for out-of-network care

Taking a closer look

PCP—Primary care physician. A doctor who decides what specialists you should see or tests you should get.

Preauthorization—A decision that care is medically necessary. Might be needed for tests, medicines, devices, surgery, etc. Sometimes your doctor will handle this, but sometimes you must get permission yourself by contacting your insurance company.

Out-of-network Care—While some plans may help you pay for care out-of-network, you will likely pay more or even all of the cost of your care out of your own pocket compared to care provided in-network.

Claim Paperwork—All forms and documents submitted by the patient or health care provider that are needed to make sure an insurance company pays for care or services.

What's on my card?

The most important tool for using your insurance is your insurance card. You need to have it with you all the time, and not all insurance cards look the same. Here's an example:

Select for more information

Every plan is different. The costs listed above are only a sample. Check your insurance card to see how much you may pay.

Here are some abbreviations that may be on your insurance card:

PCP - primary care physician
HO - hospital stay
DED - deductible
COINS - coinsurance

This information is also included in your plan's Summary of Benefits Coverage (SBC). Remember, the SBC is a complete and detailed description of your health insurance plan.

Where can I receive care?

While health insurance covers care provided by doctors and pharmacists, there are other places you can get care. Coverage and costs may vary, so be sure to check with your plan before getting care.

Public Health Clinics: Your local public health clinic or community health center provide services such as shots, birth control, HIV and STD testing, and mental health.

Retail Clinics: Some stores have clinics that take care of common health problems. You can walk in or make an appointment even at night or on the weekend.

Urgent Care Centers: Urgent care departments are same-day clinics that can handle a variety of conditions that need to be treated right away but are not an emergency.

Emergency Room: Care for emergencies.

These places might be able to provide some basic health services, including

  • Checkups
  • Treatment when you're sick
  • Care when you're pregnant
  • Immunizations and checkups for children
  • Dental care
  • Prescriptions for your family
  • Mental health and substance abuse care

Before you go, call your insurance company to find out what is covered and how much you will have to pay for health care at different places, or call the place and ask if they accept your insurance and to find out how much you'll pay.

I can help you with health insurance by sending you the right information at important times throughout the year.

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