Insurance changes starting in January 2014

By now everyone knows that their insurance plan is probably going to be different starting in January 2014.  I am going through this, too.  As such I thought I would write about some of the confusion I am working through as both a doctor and an insured person.

Today I learned about pharmacy benefits.  Apparently, like doctors, pharmacies also have contracts with insurance companies to provide services to members of an insurance plan.  Earlier today, I saw on the Washington Health Plan Finder website the words “not covered” in the “Out of Network” prescriptions column.  Initially I was concerned that this meant that I would not get any insurance coverage if an out-of-network provider writes me a prescription.  That would be really bad because I am an out-of-network provider for most of my patients.  Good news!  It turns out that the “out-of-network” term here applies to pharmacies.  I called and spoke to a customer service person who clarified this for me.  He said that an out-of-network doctor can write a prescription  for me and that it will be covered the same as an in-network doctor as long as I take it to an in-network pharmacy.  In other words, as long as you take your prescription to a network pharmacy, it will be covered (based on your plan details).  It does not matter who writes the prescription (in network or out-of-network).  This is exactly how it has always been so there is no change here.

Whew, I feel a strong sense of relief!

Best regards,

Dr. Madhavan