General questions re: referrals & prior authorizations. Confused trying to pick Marketplace HMO coverage after having employee sponsored PPO coverage for 7 years and can’t find the answers in the benefit summaries.
I've had employee sponsored health insurance for the past several years and I always chose the PPO option, so I'm a bit confused now that I'm looking at the marketplace HMOs. Here is where I could use the most clarification:
Do I have to get a prior authorization for medication I've been taking for years prior to this new insurance plan? Specifically, I have ADHD and I'm specifically trying to choose a plan that covers brand name Vyvanse (generic is not working sadly) so I can get it for less than $400 😂. I had Aetna before and while that plan did not cover any non generics at all, I never had to do a prior authorization even when I was on generic adderall. I'm going to run out of my current prescriptions mid January and I really don't want a surprise hold up at the pharmacy when I'm down to my last 2 pills.
On that same vein, would I need to get a referral for specialists that I already see? Also, what qualifies as a specialist? I know in the past I've gone in for my psych med management and been charged the specialist copay instead of an outpatient mental health copay. Same with a gynecology visit. I've checked to make sure the people I see currently will take the plans I'm deciding between, but am I going to have to find a pcp just so they can write me a referral to my current doctors?
How do I find out specifics on the cost of labs and radiology? In the past it seemed like there was a difference in billing depending on whether the tests and imaging were done in house at the doctor's office or if they sent it out/sent me to radiology center. Like I used a major medical group here called Wellstar so I'd go to a pcp or urgent care for something and if they needed an xray or tests and they could do it in office I don't think I ever got a bill for that. But if they sent me to Wellstar radiology, there would sometimes be one. Not sure if that's making sense lol. I see the coinsurance amounts for xrays & imaging and labs, but I can't find any specifics on whether that cost changes if performed in house.
If it helps any, I live in Georgia and I'm looking at Anthem BCBS Silver Pathway plans, the ones with $0 deductibles as ya girl got poor executive function, trauma, and a vengeful uterus. 😂 These are the three I've narrowed it down to, leaning towards the last one. Aside from the difference in copays/coinsurances, am I missing any major difference that might come and bite me in the ass later. Say if I end up needing a hysterectomy or a laparoscopy, idk.
Edit to add: I'm 33, lets say my zip is 30144, and current projected income for next year is about $21000. This is (hopefully) subject to change (drastically improve) assuming any one of the full time summer internships I've been applying for pans out. But in that case, it's very likely that I wouldn't even need ACA coverage anymore.
submitted by /u/cutedorkycoco
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