Understanding Insurance Coverage and Costs
Have you ever found yourself asking, “Is this going to be covered by insurance?” and “How much will it cost me?” You are not alone. These are among the most common questions people have about their insurance benefits.
When a service is covered, it means that your insurance plan will pay for some or all of the cost. Sometimes, your physician’s office will verify coverage on your behalf, but it's always good to know how you can check coverage and understand expected costs yourself before the visit or procedure is done.
How to Verify Coverage and Costs:
Contact Your Provider – Get the exact procedure codes(s) from the health care provider that is providing the service that will be used to submit the claim. This ensures you know precisely how the benefits will be paid. Without the exact procedure code, you can still check if the service will be covered, but there may be differences once the insurance is billed based on the actual procedure codes submitted.
Member Services Team – Members can call the customer service center or chat with a representative to find out if a doctor, prescription, or service is covered and how much insurance will pay. Provide the procedure code to verify the exact service. Member Service numbers can be found on the back of your ID card, on our Benefits Website, or by clicking here.
Summary of Benefits and Coverage (SBC) – Find the SBC’s for each of your benefit plans located on our Benefits Website or by clicking here.
Cost Estimation Tools – Some providers offer cost estimation tools through their apps. For example, Anthem’s Sydney App helps find nearby providers and compare in-network procedure costs. Instructions are available by clicking here. For pharmacy-related benefits, use the Express Scripts tool by clicking here. Delta Dental's cost estimation tool is available here, and for vision benefits, EyeMed's tool can be found here.
Plan Formulary (Pharmacy) - This is a listing of the medicines that are covered under your Pharmacy Benefits. Review the list to make sure the prescriptions that you need are included under the formulary and if they may need pre-authorizations. Please note that the formulary is updated twice a year: January and July. It can be found on the LSS Benefits Website or by clicking here.