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I used to get my prescriptions filled at pharmacy X and now my insurance is saying I need to go to pharmacy Y.
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Your pharmacy benefit manager contracts with specific pharmacies to provide prescription drug coverage and has a responsibility to obtain fair market value for the cost of prescriptions. In the event they are unable to reach mutually agreeable rates it may be necessary to contract elsewhere. This striving for fair market value is designed to optimize your overall insurance premiums and the cost you pay for your benefits.
You have the option to continue using pharmacy X outside your prescription benefit plan and may be able to seek discounts via consumer direct programs (drug manufacturer coupons, consumer direct discount cards like GoodRx or AARP). If you desire to maximize use of your prescription benefit coverage you will need to switch to the in-network contracted pharmacy.
I thought I was booking my annual exam with a medical professional- which is a fully covered annually by my health insurance- but after the visit I received a bill for an office visit. Why?
There are different types of services scheduled at different time intervals that allow your medical professional to give you the appropriate care. An annual exam and an office visit serve different purposes in healthcare. Key differences: An annual exam focuses on overall health and preventive care and includes a comprehensive physical examination, review of medical history, and preventive screenings (e.g., blood pressure, cholesterol, cancer screenings). This is normally conducted once a year and is classified as preventative/wellness care. An office visit addresses specific health concerns or symptoms and involves diagnosing and treating new or existing medical conditions, medication refills, and follow-up care. These visits are classified as for illness, chronic condition management, or new symptoms.
Be sure to be clear what you are requesting when booking an appointment with a medical professional so you get booked for the right type of appointment and your correct health benefit is applied. If you have insurance and are unclear about your benefit coverage for various types of visits, contact your benefit administrator prior to scheduling a visit for clarity.
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