Help Me Pick My Plan: A Guide for Employees With Chronic Conditions

With Open Enrollment in full swing, your employees likely have questions about how to choose the right plan for their specific needs. In our “Help Me Pick My Plan” series, we break down what they should look for in some of the most common scenarios. Feel free to send them a link to this post or use the information in it to help guide them. 

Dear SSSC,

We’re glad to hear your symptoms are under control — and happy to help you find the right plan so you can continue feeling your best while managing your budget. One benefit of your company switching to an ICHRA is that you’ll be able to search for plans that can help you save money on your medications, medical equipment, and other expenses. Kevin Scott, SureCo’s lead Employee Experience Specialist, shared a few tips on what to look for — and while these steps are focused on diabetes care, the same advice applies to those living with other chronic conditions, such as asthma.

Step #1: Search for condition-specific plans.

Many carriers now offer plans that are specifically designed for people with diabetes, says Scott. These plans have lower or even $0 copays on insulin and other treatments and may include additional resources, too, like reduced cost or $0 diabetes-related equipment or nutritional counseling. Carriers also offer condition-specific plans for asthma and COPD.

Scott recommends starting your search by seeing if any of these plans are available in your area. If you’re a SureCo customer, be on the lookout for plans that include something like “with diabetic care” in the name.

Step #2: Confirm your doctor is in-network

Once you’ve found a few plan options you’re interested in, give your doctor a call and confirm they’re in-network with the plan(s) you’re considering. Be sure to tell them it’s an “individual plan” NOT a “group plan.” If there are any other specialists you see regularly, confirm coverage with them, too. This way, you can continue the relationships you’ve already built with your providers.

Step #3: Choose a plan with a waived deductible for prescription drugs.

Before we get into the next step, let’s pause for a quick overview of some of the health insurance terms you’ll be navigating: 

• Deductible: The amount of money you’ll pay before your insurance starts covering some costs. A plan may include prescription medication costs as part of your deductible, have a separate medication deductible, or waive your deductible for medication costs.
• Copay: A copay is a fixed amount you’ll pay for seeing your doctor, filling a prescription, or other health services. Depending on your health plan, you may need to meet a deductible first.
• Formulary: A formulary is a list of prescription drugs covered by a health insurance plan. If a drug isn’t on your health plan’s formulary, you’d most likely have to pay out-of-pocket for it.

Because you’ll be filling prescriptions every month, choose a plan that says the deductible is waived for prescription medications, advises Scott. You’ll want to make sure that as soon as you’re enrolled in the plan, you can pick up your medication and only pay a copay. If you choose a plan with a deductible that applies to prescriptions, you’ll pay more money out of pocket from the beginning — and prescription costs, especially for non-generic drugs, can be high. 

Step #4: Check out each plan’s formulary. 

When evaluating a plan’s Summary of Benefits & Coverage (SBC), you’ll also want to check its formulary to ensure the prescriptions you take are covered. You can also see what “tier” the medication is in, which determines how much you’ll pay. Your SBC will include the copay for each tier of medications. 

A quick head’s up as you navigate SBCs: The prescription drug tier system is not standardized throughout the U.S. A plan may have anywhere between three and six medication tiers. Tier 1 drugs will have the lowest copay and typically include generic and/or preferred generic versions of prescription medications. If you take multiple medications, search for each in the formulary and look at the copay per tier in your SBC to estimate your monthly medication costs.

Key takeaways

To recap, when assessing your plan options, we recommend asking a few questions:

• Are there any plans specific to your condition available in your state?
• Are your current doctors in-network with the plans you’re considering?
• Is the deductible waived for medications in this plan?
• Are all of your medications covered in the plan’s formulary? What total medication copays can you expect each month?

Managing a chronic condition like diabetes means staying on top of your care, and it sounds like you’re doing a great job of that. We hope this guide helps you find a plan that makes it simple to keep taking care of yourself.