What Information on Your Insurance Card is Important

Use this insurance card example to understand what your own insurance card may look like and where to find important information. 

https://www.cms.gov/files/document/11818-sample-insurance-card-english.pdf 

You Have Health Coverage but Don't Know Where to Start

This roadmap explains what health coverage is and how to use it to get primary care and preventive services so that you and your family live long, healthy lives 

https://www.cms.gov/files/document/roadmap-better-care-english.pdf-0 

You  Want to Know if Your Current Insurance Covers a Medication

Access Information By Calling Member Services Representative

This option may be the best, as sometimes employers may have different coverage than what is published online. When calling, make sure you have the following information on hand: 

  1. Insurance member ID: this can be found on your insurance card  
  2. Name of the medication and the prescribed dosage 

When prompted (usually by automated system), provide your insurance member ID. Once the call representative has your account information, ask about the coverage benefits for the medication in question to determine coverage and possible out of pocket payments. 

    1. Is the medicine/neuromodulator listed as covered on your formulary?* 
    2. Is it preferred, non-preferred?* 
    3. Which tier?*   
    4. Is there a step through of other drugs required before I can get this one?  
    5. Is a prior-authorization form required? 
Computer Access

Most insurance companies also have portals and mobile apps that help you price a drug based on your current insurance plan coverage benefits. If you don’t already have access to an online portal, you can setup an account. Below are links to the registration pages for the main health insurers in the US:
United Healthcare
CVS Aetna
Anthem (Elevance)
Cigna
Carelon (Elevance)
Humana
Blue Cross Blue Shield
Kaiser Permanente
Your Medication Formulary

*Formulary:  Each health insurance plan has a list called a formulary. It describes what kind of coverage the plan provides for all prescription medications. Different levels of coverage are called tiers. Typically, lower tier numbers mean better coverage (lower out-of-pocket costs) than higher tier numbers – e.g., a Tier 1 medication has a lower out-of-pocket price than a Tier 3, 4, 5, or specialty medication. 

Prior Authorizations

Insurance plans for headache and migraine usually require something called a prior authorization. 

  1. Your healthcare practitioner must get specific approval from my insurance company (so that insurance will pay for it).  The requirements for prior authorization differ between and within insurance plans.
    • Before your plan will cover a particular drug or device (i.e. neuromodulator), you must show that you meet specific criteria.  A prior authorization is designed to make sure certain prescription drugs or devices are used correctly and only when medically necessary.  
      • During this process, be sure to communicate with both your healthcare provider and your insurance company to see if they need any additional information 
  2. Your pharmacist shared that you need a prior authorization. What happens next?  
    • If your insurance company requires (and has not received prior authorization), your pharmacy will contact your healthcare professional. 
    • The healthcare professional must contact your insurance company and submit a formal authorization request. 
    • Your insurance plan will contact the pharmacy once it has approved or denied the request. 
      • Prior authorizations usually take about a week or more to process – after that, check with your pharmacy to see if the request was approved. If the request was approved, you should be able to pick up your prescription from the pharmacy. 
  3. Navigating Pre-Authorizations: Medications 
  4. Migraine Approved Pre-Authorization: https://www.patientadvocate.org/wp-content/uploads/Migraine-Approved-Pre-Authorization.pdf 
  5. Sample Appeal Letter for Pre-Authorization Denial 

Is there an easy way to keep important information about your health coverage all in one place

Download My Health Coverage At a Glance and fill in the fields with your information. 

https://www.cms.gov/about-cms/agency-information/omh/downloads/myhealthcoverage.pdf 

You don’t understand your explanation of benefits (EOBs). How do you read this?

This sample explanation of benefits, sometimes called a fee schedule, can help you understand where to look in your own explanation of benefits for the total charges for your visit and how much you and your health plan will have to pay. 

https://www.cms.gov/files/document/11819-sample-explanation-benefits-508.pdf 

How do you make the most of your coverage

This checklist is a quick reference on how to make the most of your health coverage. 

https://www.cms.gov/about-cms/agency-information/omh/downloads/5-ways-to-make-the-most-of-your-coverage.pdf 

Roadmap to Behavioral Health

This companion guide to the Roadmap to Better Care can help you understand what mental health, and other behavioral health care services are available to you and how to seek out care. 

https://www.cms.gov/files/document/roadmap-behavioral-health-english.pdf 

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