Insurance renewal season, and what to check before January

Dear You,

Every October my HR portal sends me an email with a cheerful banner and a deadline, and every October I think “I’ll get to it,” and then it’s November 9th and I’m reading a formulary PDF on my phone in a parking lot. Last year I made a checklist so this year I wouldn’t. Here it is.

A caution before the list: plans are different, states are different, employers are different. These are the questions I learned to ask, not the answers you’ll get. The answers come from your plan, your HR team and your prescriber, and if there’s a medication decision hiding in any of it, that part belongs in the room with your care team.

Before you open the enrollment portal

1. Find your current prior authorization and its expiry date. Mine was approved for twelve months, and twelve months from the approval date was not January 1st. Those are two different clocks. Put both on the calendar.

1. Check whether the medication is on next year’s formulary, not this year’s. Plans publish the new year’s list during open enrollment, and it can be a different document with a different link. Search for the drug name and look at the tier.

1. Look for the words “step therapy” and “quantity limit” next to the drug. They mean the plan may want you to try something else first, or may cap how much you get per fill. Neither is a no. Both are things to ask about.

1. If you’re choosing between plans, do the math on more than the premium. A cheaper monthly premium with a higher-tier copay for the one prescription you fill every month can cost more by March.

Questions for HR

1. Ask whether the plan’s pharmacy benefit is changing managers. A new pharmacy benefit manager can mean a new formulary, a new prior authorization process and a new mail-order pharmacy, even if the plan’s name stays the same.

1. Ask whether an existing approval carries over. Sometimes a plan change resets the prior authorization and you start the paperwork again in January. Better to know in October.

1. Ask if there’s a continuity-of-care window. Some plans give you a grace period of a fill or two while a new authorization is processed. Some don’t. The HR benefits inbox has answered this for me faster than the insurer’s phone line.

Questions for the pharmacy and the manufacturer

1. Ask the pharmacy what your copay would be under the new plan, if they can run it. Sometimes they can’t until January, but it’s worth the question.

1. Check whether a manufacturer copay program applies and whether it renews. Several have an annual cap and a re-enrollment step. Mine quietly expired on December 31st one year and I found out at the counter.

1. Ask about the mail-order option. For me it was cheaper for a 90-day supply, but it also meant a longer lead time, which matters if an authorization is about to lapse.

The calendar reminders I set

• October 1: open enrollment is coming, find the folder.
• Two weeks before the prior authorization expires: call the prescriber’s office and ask them to start the renewal.
• December 15: confirm the copay card renewed and the first January fill is scheduled.
• January 5: check that the first claim of the year processed at the price I expected.

None of this is fun. It is forty minutes in October that saves a panicked afternoon in January, and I say that as someone who has had the panicked afternoon. The pharmacy counter is a terrible place to learn that a form expired. The kitchen table in October is a much better one.

Want to tell me something? Reply to any Low Volume email, or write to me here. I read everything.

Getting Quiet shares lived experience, general education, and practical tools. For medical decisions and individual treatment questions, talk with your qualified care team.