Psoriasis is a chronic skin condition that can cause itchy and scaly skin. Treatment can help you manage the condition, so it’s important to understand your health insurance coverage.
Understanding your health insurance benefits can help you get the most out of your coverage, especially when you’re living with a chronic condition such as psoriasis.
While it may be possible to manage psoriasis through diet and lifestyle strategies, regular checkups with a dermatologist and medications may also be essential components of an effective psoriasis management plan.
Health insurance is coverage that helps you pay for medical care and services. You pick an insurance company and a plan and pay a set rate each month. The insurance company then pays for a portion of all the covered healthcare services you receive. Often, you’ll need to pay additional costs, such as a deductible or copayments for certain services.
When you have a chronic condition such as psoriasis, it’s important to have an insurance plan that will cover the services you need. As you look through your plan, you’ll likely see terms such as these:
- Benefits: Benefits are the expenses your insurance plan covers.
- Claims: A claim is a bill sent to your insurance company for a medical service.
- Copayment: A copayment is a set amount you owe each time you receive a specific service. For instance, you might pay $20 each time you visit your primary care doctor.
- Coinsurance: A coinsurance payment is the percentage of the cost of a service that will be charged to you. For example, you could have a coinsurance of 15% of the cost of a hospital stay.
- Deductible: A deductible is an amount you’ll need to pay before your insurance company starts to pay your medical costs.
- In-network: An in-network healthcare professional or facility is part of your insurance plan’s network. Typically, you’ll pay less to see in-network healthcare professionals.
- Out-of-network: An out-of-network healthcare professional or facility does not participate in your health insurance plan’s network. Out-of-network services are generally more expensive.
- Out-of-pocket maximum: This is the most you’ll pay for medical services in a single plan year. Once you hit this maximum, your insurance plan will cover 100% of your costs.
- Premium: Your premium is the amount you’ll pay your plan each month to keep your coverage active.
There are multiple types of health insurance plans:
- Exclusive Provider Organization (EPO): An EPO pays for care from only healthcare professionals who are part of the plan’s network, unless you’re having a medical emergency.
- Health Maintenance Organization (HMO): An HMO is a health insurance plan that limits the coverage you can receive from healthcare professionals who are not part of the plan’s network.
- Preferred Provider Organization (PPO): In a PPO, you pay less when you receive care from healthcare professionals who are part of your insurance company’s network.
- High deductible health plan (HDHP): An HDHP is a plan with a high deductible but low premiums. Often, preventive services, such as vaccines and annual checkups, are covered before you’ve paid your full deductible.
It’s important to make sure that any insurance plan you have will cover your psoriasis treatments and medications. You can typically find a list of services and treatments a plan covers on the insurance company’s website. Many companies have a feature that allows you to enter terms in a search box to check for coverage.
The list of prescription drugs that your plan covers is called a formulary. You can search a plan’s formulary for the medications you take for psoriasis. You can also try searching plan benefit documents for specific treatments. If you’re still not sure, you can call the plan and talk with a representative.
If you have psoriasis, your treatment team likely includes some specialists, such as a dermatologist, a rheumatologist, and a physical therapist. It’s a good idea to make sure your insurance plan covers visits to these specialists.
Some insurance plans will ask that you get referrals before you see any specialists. This means you’ll need to visit your primary care doctor and they’ll need to write you a referral directing you to see the specialist. Your insurance company will not pay for the specialist visit if you do not have this referral.
It can be helpful to compare the costs of your treatments and prescriptions with the copayments or coinsurance costs of multiple plans.
For instance, if you take methotrexate, you can search for its cost with several insurance plans. You can see whether it’s part of a plan’s formulary, whether you’ll need to pay your full deductible before it’s covered, and what the copayment or coinsurance cost will be.
An insurance navigator can help you find the best plan for you.
Prior authorization is an approval that your health insurance plan may require before it will cover specific treatments and medications. This is sometimes required before you receive care. For example, you might not be able to schedule a surgery until your insurance company confirms that it will be covered.
If your insurance company denies your coverage request, you can appeal the decision. Typically, this requires sending additional information to your insurance company, such as detailed medical notes from your doctor that explain why you need the procedure. You can read more about appeals.
There are multiple resources that can help you afford your prescription medications. Checking to see what your plan covers is a good way to start. You can also:
- Ask your doctor whether a generic medication is an option for you.
- Use any available prescription discount programs.
- Look for coupons for your prescription.
- Sign up for pharmacy discount cards.
Routine visits to a dermatologist play an important role in managing psoriasis.
When reviewing your coverage, pay attention to copays, out-of-pocket maximums, and any restrictions or limits on the number of appointments. Doing this can help you build a budget to support checkups.
You can also talk with your doctor’s office about payment plans or other assistance they may offer if you are underinsured.