New Insurance

My family has employer-provided health insurance.  A few months ago I heard that the company was considering switching to a new carrier.  I was horrified.  We have a pretty good policy, and I don’t want anything screwing up my coverage.

Open enrollment came and went, but coverage options remained the same and nothing more was said about a new carrier.  Whew!  What a relief!

Tonight I was informed that the company can save a significant amount of money by switching.  Great for the company, but I don’t expect it will be good for my pocketbook.  They’re not going to save $75K by giving me better coverage.  Before things are final, however, I have the opportunity to make a list of questions – details that the owners might not think to ask.

I need your help so I don’t forget to ask anything important.

My current list is:

  1. Are the same doctors and hospitals covered on this new plan as on the old one?
  2. What is the coverage if we choose a physician not on the preferred provider list?
  3. How long does it take to process claims?  How quickly/slowly will my doctors be paid?
  4. What will the new co-payment be for coverage?
  5. Currently, if I see more than one doctor on the same day, I owe only one co-pay.  How will the new policy handle this situation? 
  6. What will be the annual out-of-pocket individual/family limit?
  7. What is the coverage on preventive care?  What is the annual limit on this benefit? (existing policy is $300 per year)
  8. Are both adult and childhood vaccines covered?
  9. Are travel vaccines included under preventive health coverage?  Or covered at all?
  10. How is coverage handled for accidents/illnesses that occur away from home?
  11. Does this policy cover foreign travel?
  12. Is the medical necessity of testing left to the discretion of my physician who holds a medical degree, or must he obtain pre-approval from someone who did not attend medical school?  ( MRI, ultrasound, CT, lab work, x-rays, etc.)
  13. Are physician-prescribed orthotics covered for conditions other than diabetes?  If so, what are the details on this coverage?
  14. Are referrals required from our PCP for us to see specialists?  If so, will existing referrals be honored, or must new referrals be written?


  1. Will insurance continue to cover my current prescriptions?
  2. Are medication decisions left to the discretion of my physician who holds a medical degree, or must he obtain pre-approval from an insurance company employee who did not attend medical school?  If some medications require pre-approval, which ones?  How long does the approval process take?
  3. Our current prescription coverage has flat copays of $10/$25/$40.  What is the prescription co-pay on this new policy?
  4. Is it possible to get a copy of the formulary to know which medications are listed in which tier?
  5. Does money spent on prescriptions count toward our annual out-of-pocket maximum?

I have until tomorrow morning to add to this list.
Can you think of other things I should be asking?

Edit to add:

I’ve also added questions about PT/OT limits/exclusions.  Last year we were allowed 20 PT visits annually.  This year it dropped to 15 visits/$2000.

I also added a question about surgery coverage. Our current policy will only pay for surgery within two years of diagnosis, which means I might be SOL for having our current insurance pay to fix my shoulder if it ever becomes necessary.  A longer time limit under the new plan would be a welcome change.


7 thoughts on “New Insurance

  1. 1. Will your co pay change for blood work, x rays etc?
    2. If you are on a biological med be sure to check what the co pay will be on it. Mine really skyrocketed when we changed plans last spring.
    3. Although I am not a diabetic I know that the cost of meds and supplies for diabetics also went through the roof.
    4. Will you be able to continue to use your own pharmacy. Some of my meds now HAVE to be ordered through the mail. There is no option to get them from the local pharmacy.
    5. Will you have a new deductable for procedures, tests, doctors visits?

    • THANK YOU! I thought of #4, but forgot to write it down. Some of the other stuff, I just assumed. I think it’s standard to credit all moneys paid on the old policy, but the way things are changing, I’d better find out for sure. Obviously I shouldn’t be making any assumptions here.

  2. I would ask for costs associated with emergency room visits (given your recent experience). Depending on when you change, you should ask if your current out-of-pocket/deductibles transfer to the new policy. As if there will be an “upgrade” option available. My company offers a basic plan for everyone, but also for an additional fee, employees can upgrade their plan for a lower deductible and lower prescription. (The lower deductible if you use is more than pays for the extra premium.) You should also ask if the insurance offers discounted prescriptions via their mail order pharmacy. You may not want this option, but it would be nice to know that it’s there. Ask if there are different deductibles for in-network and out-of-network providers.

    There are just so many variables, it’s hard to list them all but I think you’ve got a terrific start on the list.
    Good luck.

    • Thank you. I’ll add ER to the list.

      After Mary’s comment I added questions about applying money spent this year to the new policy (I think that’s pretty standard, but I want to double check).

      We can choose between a PPO plan or Group Health, but there’s not an upgrade option. I’ll ask if it’s a possibility, though, since the details are being ironed out today.


  3. Oh sorry, I meant an new deductable amount. I think you can apply what you spent on the old plan to the new plan deductable. Our deductable jumped from $1000 to $2000 last year.

  4. Pingback: Insurance Changes « ∞ itis

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