With the changes the Affordable Care Act (ACA) has brought to health plans, there are many options available to you and your family. Comparing the new individual “metallic” health plans is not always apples to apples. Consider these four key elements when choosing between plans so you end up with what’s right for you.
Deductible
Preventive benefits, such as vaccinations and annual physicals, will be covered in full by your plan, which means you’ll pay nothing out-of-pocket, as long as you visit an in-network doctor or pharmacy for these services. For services like a visit to the doctor’s office, you’ll pay a fixed amount, and Premera will take care of the rest. Other services will apply to your deductible.
A deductible is the amount of money you pay each year before your health plan begins to pay for these services. Generally, the lower your monthly payment, the higher your deductible and vice versa. You should consider carefully whether you would rather pay a lower monthly rate, but know that you will need to pay a greater amount out-of-pocket if you need medical care, or pay more each month, but have lower out-of-pocket costs if you get sick or have an accident.
Out-of-Pocket Max
Out-of-pocket max is the maximum amount you could have to pay toward your allowable healthcare costs in a year, as long as you receive care from doctors and hospitals in our network. In 2015, the highest out-of-pocket max that any plan can offer is $6,600 for an individual and $13,200 for a family. After you reach this amount, your plan will pay 100% of allowable charges. All of your benefits apply to your out-of-pocket max, as long as your benefits are provided by an in-network doctor, hospital or pharmacy. The same principle as a deductible applies to out-of-pocket max – choosing a plan with a higher out-of-pocket maximum will lower your monthly rates, but you will need to pay more out-of-pocket if you need serious medical care.
Network
A network is a group of doctors and hospitals that contract with Premera to provide services at an agreed amount. We understand the trusted relationship you have with your healthcare provider is important, so when you compare options for a new plan, this is something that you should take into consideration. Are your healthcare providers covered by the new plan you want to buy? If not, you can still see your healthcare provider, but you will face higher out-of-pocket costs. Services provided by an out-of-network provider will not count towards your in-network deductible or out-of-pocket maximum.
Pharmacy Coverage
While prescription drugs are covered by all of our plans, each plan may pay pharmacy claims differently. Depending on the plan you choose, you may be charged a copay or coinsurance or have to pay the full cost of your prescription drugs until you meet your deductible.
If you or anyone in your family regularly takes prescription medications, we recommend that you check each plan to find out what your medications would cost. There may be a significant difference in price per plan. You can see how any drugs you take would be covered by our plans by using the Rx search tool in the Pharmacy section of premera.com. Any money that you spend on prescription drugs, covered by your plan and purchased through an in-network pharmacy will contribute to your out-of-pocket max.
