Understand how your insurance worx?

Insurance can be confusing with all the terminology, rules & conditions. This basic insurance primer can help! Understand your personal insurance and learn tips to help you afford your diabetes supplies and medications. Feel free to ask a question or leave a comment below.

Terminology:

Co-Pay/Co-Insurance

A co-payment or co-insurance is just that — you and your insurance agree to co-pay for a healthcare expense. Insurance plans require you pay either a percentage or a fixed amount of the cost of a drug or health related expense. Generally your payment is structured as a tier system as seen below.

Fixed Co-Pay PlanPercentage Co-Pay Plan
$20 for tier 1 drugs20% cost paid by you
$35 for tier 2 drugs50% cost paid by you
$80 for tier 3 drugs70% cost paid by you

*Amounts of co-payment/co-insurance will depend on your insurance plan.

Deductible

The deductible is the amount of money you must pay out of your own pocket before your insurance will start paying/covering for other healthcare expenses. This can be a very small amount or thousands of dollars.

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Insurance allowable

When insurances contract with venders who supply drugs or medical supplies, the venders agree to accept a maximum or discounted amount for various items.

For example, a pharmacy may charge $800 for a medication, but the insurance may only allow a charge of $650 based on their contract with the vender. The pharmacy accepts the $650 as payment-in-full. The insurance will pay up to $650, minus co-pays and deductibles.

Maximum Out-Of-Pocket

Total amount or the maximum you will pay out-of-your-own-pocket toward your medical expenses.

Once you have paid up to your maximum amount set by your insurance, your insurance will pay for any additional medical expenses 100%. This means no more co-pays or deductibles for covered healthcare expenses! I say covered, because if you have an expense that your insurance would not normally cover, you will need to pay for that.

Anything that you pay for covered healthcare expenses (deductibles, copays, etc.) go toward meeting your out-of-your-pocket maximum.

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