Agency for Healthcare Research and Quality

Wise Health Care Choices  »  Medical Care

Know Your Health Plan

  1. Find out what the plan covers. Ask your employer, insurance company, or use the Web site you are given to get information.

  2. Read your health plan’s policy and member handbook or Web site information. If you don’t understand something, check the commonly asked questions, if available, on the insurer’s Web site or call or email your questions to the health plan’s member services.

  3. Find out how services are paid for. What is your role to cover payment?

  4. If you belong to a managed care plan, find out how to get a list of the plan’s providers. Ask how you find out about changes in covered services or in providers.

  5. Find out if the health plan has an advice hotline. Often, this is a toll-free number you can call 24 hours a day.

  6. Find out if services are covered when you are out of your home state or in another country. Find out if emergency evacuation expenses are covered.

  7. Find out if and how prescription drugs are covered. Find out if you have a co-pay for medicines and how much it is for generic and brand name drugs. Does the plan have a preferred list of medications (formulary)? If so, get a copy from the health plan. Take it to each doctor visit.

  8. Do you have to use the plan’s mail order pharmacy for medications you take on a regular basis? A mail order pharmacy may charge you the same co-pay amount for 90 days that you would pay for 30 days at a drug store.

  9. Find out how to file a complaint and an appeal if you and your doctor do not agree with the health plan’s decision to provide care.

Be Involved in Your Health Care

  1. Discuss your needs with your doctor or health care provider.

  2. Ask questions. Ask for clear answers. Make sure you understand what you are told to do. Take notes. Ask another person to go with you, if necessary.

  3. Follow your doctor’s advice. If you can’t, let the doctor know.

  4. Learn about your condition from your doctor. (See, also, Gather Facts.)

  5. Keep track of your medical needs. (See Medical Record.)

  6. If you are not satisfied with the service you get, discuss your concerns with the doctor or health care provider. If you are still not satisfied, consider using another provider.