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Epilepsy Blog Relay™: Leila on Navigating Health Insurance

20160327_130705This post is part of the Epilepsy Blog Relay which will run from November 1 through November 30.  Follow along and add comments to posts that inspire you!

Health Insurance and Epilepsy

Shopping for insurance can be overwhelming.  There are so many things to think about: drug formularies, whether a plan covers your doctors, co-payments, deductibles, the list goes on and on!  It’s absolutely possible to sort out all of these things without losing your mind, even if it doesn’t feel like it!  Read on for some tips to make your hunt for insurance a little easier.

Paying a Premium

Your premium is the amount you pay the insurance every month. This money is just to keep your insurance coverage.  It generally does not contribute to your deductible and does not pay for any medical services.


This is the money you pay for medical services.  When you go to the doctor, have a test done, or any other medical service, you pay a set amount for it.  The amount you pay depends on your insurance plan.  Generally, the higher your monthly premium, the lower your payment for services. This is ideal for those of us who go to doctors frequently. If you don’t use services often, you may want to opt for a plan that has a lower monthly premium but higher cost of services.  If you’re able to choose your plan, calculate how often you go to the doctor to determine whether you want to pay a higher premium or higher co-payments.

What is a deductible?

A deductible is the amount of money you must pay before the insurance company begins to pay. If the deductible is $1000, for example, then you will pay $1000 for medical services before the insurance company pays any.  Some insurance companies pay for services before the deductible is met.  Look to see if this is the case; it can save you money! Check and see if the money you pay for your prescriptions goes towards your deductible.  With my previous insurance, my prescriptions did not go to my deductible. If my deductible was $1000, this meant that I still had to pay $1000 before insurance would take over payment for services. If you are purchasing prescriptions often, it can be a benefit to have those funds go towards your deductible.  Always check to see if the plan has more than one deductible.  I haven’t seen many of these, but some have separate deductibles for medical services and prescriptions.  If you have a family, look to see if there is a family and individual deductible.  Some plans have deductibles that apply to each person and another deductible that applies to the family.  For example, a personal deductible may be $1000 before insurance kicks in, while a family deductible may be $2000 and all payments made by members of the family contribute to it.  If the combined members of the family hits $2000 before an individual hits $1000, the insurance will begin to cover costs.

Drug Formularies

Always make sure your medication is covered under your insurance plan.  Look for the plan’s drug formulary which lists the medications covered and the amount they will pay for.  Some companies have different tiers to classify drugs and, depending on the medication, they will cover certain amounts based on the tiers.  Check your medicine with each specific plan, not just with each insurance company, to make sure you’re covered. It may not be, and you’ll have to talk with your doctor about switching medications.  If you’re on a drug that has different variations, like Keppra vs. Keppra ER, you need to see if your specific version is covered.  At one point in my life, Keppra ER wasn’t covered but Keppra was.  

In some cases, the generic form of your pill will be covered or it will be cheaper than the name brand. With my previous insurance, Keppra wasn’t covered, but it’s was. Always talk with your doctor about your medications and what your options are to find one that is covered. Never switch to another medication without talking to your doctor.  On a related note, make sure your pill size is covered.  I was on a medication where the 25 mg and 50 mg tablets were covered but the 75 mg was not; I had to take two pills instead of one just because of it!

Doctor Coverage

Each plan varies on the doctors that are covered.  Sometimes they are the same across one insurance company, sometimes they aren’t. Just like your prescriptions, make sure to check if all of your doctors are covered. If you have a provider that isn’t covered, check with his/her office to see how much it costs to go to this doctor out-of-pocket.  It may not be much more to pay for an appointment without insurance.  You can also prioritize your doctors.  For example, you probably need the specialists you go to but, if you don’t go to the podiatrist every year, it won’t be as serious if he/she isn’t covered on your plan. (Note: You should attend all your medical appointments as often as they recommend. Do not stop going to a doctor unless you have consulted with him/her.)  Different doctors have different costs (specialists sometimes have higher co-pays), so make note of that when calculating your annual medical costs with each plan.

Odds & Ends

Some insurance companies prefer you to use specific pharmacies.  In my case, it is a better deal to use a mail order pharmacy as opposed to a store (CVS, Walgreens, etc).  My insurance company covers more of the cost that way.  See if your insurance does something similar. 

Always talk with your doctor about your different concerns.  If you have questions about specific insurance plans, contact that company. They’ll know how to answer your question based off of their policies.  Do your research, take notes, ask questions, and try to stay calm.  It can be overwhelming and frustrating to navigate insurance but when you know exactly what you need and how to find it, you’ll be sure to conquer the world of health insurance!

NEXT UP: Be sure to check out the post tomorrow by Chantal on LivingWellWithEpilepsy. You can also read the same post on her site http://levenmetepilepsie.com/ in Dutch. For the full schedule of bloggers visit the Participants gallery.


DON’T MISS IT: Don’t miss your chance to connect with bloggers on the #LivingWellChat on November 30 at 7PM ET.

Follow Leila Shields:
Leila shares stories on stigma and epilepsy based on her experiences and what she hears from others. She was diagnosed with Epilepsy at age 8 and is based in Pennsylvania.

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