Allergies and asthma are chronic health conditions. Many people with asthma and allergies require long-term use of medication and regular doctor visits for this reason. If you have asthma and allergies, you will need good health insurance coverage to stay healthy. Open enrollment season is when you can add or change your insurance plan if you need to. Use the following information to better understand how and when to check out your options for health insurance coverage.
Why is it important to have good health insurance coverage for asthma and allergies?
As you likely know, allergy and asthma health insurance coverage can be hard on the wallet. Coverage issues vary widely from plan to plan. Choosing the wrong plan may end up being a costly mistake. Good coverage will give you access to the care you need that is more affordable.
What are the risks of not having good allergy and asthma health insurance?
If you try to cut back on care or medications to save out-of-pocket costs, that type of choice can be risky for your health. People with high-deductible health plans may choose to skimp on medical care and preventive medications to keep costs down. They tend to go to the doctor less and not get prescriptions filled. They tend to not use medication as prescribed. If you have asthma, that may mean you may not refill or use your albuterol inhalers for quick relief, or take your daily maintenance inhalers. If you have severe allergies, you may not refill your epinephrine auto-injectors. This is risky. It’s important to follow your treatment plan, especially when it comes to managing asthma and allergies. An important way to maintain your health is to pick the right healthcare plan.
How do you keep costs from becoming a burden in asthma and allergy care?
The best way to make sure you have the right health insurance coverage for your allergies and asthma is to shop around. Shopping around for health insurance can reduce your overall costs. Start by reviewing your current insurance plan. Use this information to gain insight into what your costs are. Doing so will allow you to stay on top of healthcare costs each year. It will also give you a way to verify that your current plan meets your healthcare and financial needs. You can use this information to compare your current plan and costs to others available to you. You will then be able to tell if the plan you have is the right one for you, or if another available plan is a better choice.
How do you know what health insurance plan is best for you?
When you compare health insurance plans, your first impulse may be to choose a plan with lower monthly premiums. But those plans will have higher copays and deductibles. Do not base your decision only on the premiums and deductibles when you compare plans. Instead, pick a plan that best suits your healthcare needs based on the overall cost to you. Do you need frequent doctor visits or routine medications? If so, a plan with a low monthly premium could end up being the more expensive option. Depending on the plan, you can face unanticipated costs due to:
- high deductibles
- drugs not being on an approved list, or formulary, for the insurance plan you have
These out of pocket costs will end up with you taking on a greater financial burden. This is true especially if you have a chronic condition such as asthma or severe allergies. Another option, if available from your employer, is to sign up for an employer-sponsored Flexible Spending Account, also called a Flex Spending Account. This allows you to set aside a portion of your earnings on a pre-tax basis to pay for medical expenses.
What else should you consider when choosing a health insurance plan?
Many asthma and allergy tests are covered by insurance. But insurance companies may place limits. Take a look at the coverage you may need for tests and procedures. Tests and procedures to ask about include:
- skin prick allergy tests
- allergy blood tests
- spirometry to measure lung function
- immunotherapy (allergy shots and tablets)
- fractional exhaled nitric oxide tests (FeNO)
- oral food challenge
- exercise challenge
How do you determine the annual total cost of health insurance coverage?
Total costs involve many factors. Those factors can include:
- Premiums: what is the monthly or annual cost of the insurance you will have to pay?
- Cost sharing: what are the deductibles and copays you pay?
- Provider network: check to see if your doctors are in-network or out-of-network. Out of network doctors will cost more.
- Formulary: check to see if the medication(s) you need are on the plan’s approved list. Drugs not on the formulary list may not be covered. You can find the list of approved medications on your health insurer’s website; or you can call and ask the insurer to send you a copy of the formulary list by regular mail or email.
- Coupons and discounts: find out if you are eligible.
- Non-covered services: you will have to pay for any non-covered services or procedures.
- Coverage for new drugs: insurance plans may or may not approve new drugs for reimbursement.
You can find information about medications in your formulary on your health insurer’s website. Your plan’s name is on your insurance card. If you are not able to find the formulary online, call and ask the insurer to send you a copy either by postal mail or email.
How can you figure out your total out-of-pocket costs for a given plan?
Look at what you spent during the current year to get an idea of your out-of-pocket costs. Use those numbers to project what you will expect to pay for the coming year with your current plan. To calculate your healthcare budget, add up your out-of-pocket expenses:
- Monthly premium for the year
- Prescription copays for the medications you expect to use for the year
- Primary care doctor visit copays for the doctor visits you expect to use for the year
- Specialist visit copays you expect to use for the year
- Lab/test fee copays you expect to use for the year
Once you have this information, you can use it to compare with other plans for which you are eligible. It is important to take into account all the fees involved in treatment. For example, some people who undergo allergen immunotherapy shots may see one fee for the allergen extract and another fee for the actual injection.
How can you choose the best deductible for your health coverage?
Do you have moderate-to-severe asthma that requires frequent doctor visits and prescription refills? A low- or no-deductible health plan may be best. Are your asthma and allergies under control? Do you expect only a few doctor visits and prescription refills? If so, a high-deductible plan may be a good option for you.
When can I change plans?
You can find a health plan at any time of year at Healthcare.gov.
Healthcare.gov is also referred to as the Health Insurance Marketplace. The Health Insurance Marketplace is a place where people can obtain insurance if they do not have benefits through their employer or another government program. Examples of government programs are Medicare, Medicaid and Tricare.
Open enrollment is the annual time period when your employer or government-sponsored healthcare plans allow you to change health insurance plans. Most people add or change plans during open enrollment season. People who have plans through the Health Insurance Marketplace can also participate in open enrollment. Open enrollment is typically sometime during October to December each year for most employers. Open enrollment for Healthcare.gov usually begins on or around November 1 each year.
You are eligible for Medicare if you are 65 years of age or older and a U.S. citizen. If you are not 65 or older, then you still may qualify. People who are entitled to Social Security disability benefits or have a specific medical condition (amyotrophic lateral sclerosis (ALS) or kidney failure requiring dialysis) may qualify for Medicare. Medicaid, which is free or low-cost care in most states, provides health coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. In some states, the program covers all low-income adults below a certain income level.
How can you get help with understanding your health insurance options?
Now more than ever, you have more choices for your health insurance. You get to decide about your health services, providers and medications. But you must be more proactive, engaged and informed to navigate this process. Although it can seem complicated, there are resources available to assist you. Aimed Alliance, a national organization, has three guides to help you navigate this process:
- Open Enrollment: Understanding Your Health Plan and Your Cost-Sharing Responsibilities (PDF download)
- Medicare Open Enrollment: Understanding Your Health Plan and Your Cost-Sharing Responsibilities (PDF download)
- Open Enrollment: Selecting Benefits for Your Employees to Protect Their Health (PDF download)
What are other ways you can save on out of pocket expenses?
You may not think about talking to your doctor about healthcare and prescription medication costs. But you should. Doctors discuss costs with patients in about 30% of visits, a study revealed. Barriers exist, though – some doctors are not well prepared to discuss financial concerns. Think of out-of-pocket expenses as part of your overall treatment plan. It’s a factor in making an informed healthcare decision with your doctor. You can also bring up your costs with others on your healthcare team:
- nurse practitioner
- physician assistant
- school nurse
- asthma educator
- respiratory therapist
Many pharmacists now counsel patients on medication use and affordability. Doctors may recommend generic medications that are – in most cases – less expensive. They may have product samples or coupons. The costs of asthma inhalers and other medications can sometimes vary from pharmacy to pharmacy. Shop around online for the best price and compare costs of medications before filling your prescription. Use GoodRX.com to compare medication costs and get coupons.
The best way to make sure you have the right health insurance coverage for your allergies and asthma is to shop around. Shopping around for health insurance can reduce your overall costs.
Check out websites and follow social media for the medications you use. Some pharmaceutical companies offer coupons and discounts for medications. However, be aware that some insurers may decline to count this third-party assistance toward out-of-pocket costs. Insurers created “co-pay accumulator adjustment programs” which allow access to high-cost prescription drugs but do not apply to deductibles or out-of-pocket costs. This can leave some patients with no affordable coverage option. Talk with other budget-minded patients and parents. Ask for advice and tips on how they handle healthcare expenses. Join a support group. Sometimes they host guest speakers who bring product samples or coupons. Check out the resources and webinars offered by Needymeds.org. Needymeds can help you better understand how to save on your healthcare costs.
What if you still incur unanticipated out of pocket costs?
Establish an emergency fund. This will help you cover the unexpected costs of emergency care or hospitalization for a severe asthma attack or allergic reaction. This is where high copays can be difficult to afford.
What is the cost of asthma inhalers without insurance?
Asthma is an expensive condition for many patients and caregivers, especially for those who are without insurance, according to GoodRX.com. People with health insurance may be able to avoid the full burden of these costs, but some inhalers may be excluded or not fully covered, resulting in higher co-pays. Here are resources to help you better afford for your asthma and allergy medications:
- What if I Can’t Afford My Asthma Medication?
- What if I Can’t Afford My Allergy Medications?
- What if I Can’t Afford My Epinephrine Medication?
Key Health Insurance Terms to Know
Copay: A fixed amount you pay for a healthcare service when you receive that service.
Premium: The price you pay per month for health insurance, whether you use it or not.
Deductible: The yearly amount you pay upfront for all medical care, before health insurance kicks in to pay most expenses. In high-deductible health plans, the monthly premium tends to be lower. In low- or no-deductible health plans, the monthly premium tends to be higher.
In Network: In-network doctors and health professionals participate in your health insurance provider’s network. This ensures your doctor visits and treatments are covered under your health insurance plan.
Out of Network: Out-of-network doctors and health professionals do not contract with your health insurance provider. Some health plans may not cover doctor visits or treatments from out-of-network providers. This can lead to higher prices for patients.
Cost Sharing: The share of costs covered by health insurance that you must pay out of your own pocket. This includes deductibles and copays, but not premiums, billings from out-of-network providers and/or services not covered by health insurance.
Reviewed by: Leandra Tonweber, PA-C, AE-C, is a Certified Physician Assistant and certified asthma educator with 15 years of experience in asthma, allergies and immunology. She joined Allergy & Asthma Network in 2021 to serve as an Asthma Coach. She has worked as a medical assistant and health educator for medical practices in Rochester, New York and Charlotte, North Carolina.