Open Enrollment Resource

Why Open Enrollment Matters
 

• Insurance benefits can change each year (costs, covered medications, in-network providers). 

• Specialty medications, infusions, and procedures may be affected most. 

• Reviewing your plan now helps avoid surprise bills or care delays. 

What Patients Should Do Right Away

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• Review your current plan and compare it with new options. 

• Check whether your doctors, infusion center, and specialists remain in-network. 

• Verify your medications are still covered (and what tier they’re on).

• As soon as you receive your 2026 insurance card, submit it to us [link to submission form/portal]. 

 

Questions to Ask When Choosing a Plan

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General cost structure

  • What is the monthly premium? 

  • What is the annual deductible? 

  • What is the out-of-pocket maximum (for in-network; also for out-of-network if applicable)?

  • What is the coinsurance for different types of services (e.g. specialist visits, infusions, hospital stays)? 
  • What are the copays for visits, labs, imaging, etc.? 

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Prescription drug coverage

  • Is my current medication(s) on the formulary? If yes, what tier? 
  • If my specialty drug is self-administered vs infusion, is it under pharmacy benefit or medical benefit? 
  • Are there prior authorization, step therapy, or other restrictions for my meds? 
  • Is there a required specialty pharmacy or can I use a local pharmacy? 
  • What will I pay per fill (copay or coinsurance) after meeting deductible? 
  • How do copay assistance/coupon cards work under this plan (do they count toward deductible / out-of-pocket max)?

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Provider access / network

  • Is my usual provider (specialist, infusion center, etc.) in network? 
  • What is the cost if I see an out-of-network provider? 
  • If I need hospital/infusion center services, are those facilities in network? 
  • What are the network restrictions (e.g., referrals required, primary care gatekeeper, etc.)?

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Specialty services / infusions / procedures

  • For infusions: what is my cost-sharing (coinsurance/copay) for the facility fee, drug cost, administration cost? 
  • If the drug or procedure requires medical benefit, what portion is covered, what documentation is needed? 
  • Will I need pre-authorization or other prior approvals? 
  • Are there limitations on how often services are allowed? 
  • Does the plan cover new or emerging therapies?

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Medicare / Medicare Advantage (if applicable)

  • If I choose Medicare vs. Medicare Advantage, how will my medications be covered (Part B vs Part D)? 
  • What network restrictions apply under Advantage plan vs Original Medicare? 
  • What are the prescription drug caps or maximum out-of-pocket for drugs? 
  • What supplemental coverage might I need?

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Miscellaneous / fine print questions

  • What counts toward deductible, coinsurance, and out-of-pocket max (e.g., drugs, infusion, specialty services)? 
  • Are there separate deductibles for medical vs pharmacy vs specialty medication? 
  • Are there copay-accumulator or benefit accumulator programs that may impact my use of copay assistance? 
  • What are the copays or costs for labs, imaging, durable medical equipment, physical therapy, home health, etc.? 
  • What is the appeals / claim denial process? 
  • Are there extra benefits or programs (e.g. telehealth, convenience options, wellness, disease management)?

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Helpful Resources

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Open Enrollment:

•    YouTube: Open Enrollment to Medicare – Arthritis Specific Tips
•    Preparing for Open Enrollment 
•    Arthritis Foundation: Preparing for Open Enrollment 
•    Arthritis Foundation: Open Enrollment Checklist 
•    Arthritis Foundation: Open Enrollment Edition! 

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State Health Insurance Assistance Programs (SHIPs)

•    What Is a SHIP and How Can It Help Me?
•    State Health Insurance Counseling Program (SHIP) - Oklahoma Insurance Department

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Oklahoma Arthritis, Oklahoma Neurology Center, and Oklahoma Family Wellness Center Accepted Insurances:

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​​​​​​​​​​​Specialty Services & Infusions

1.    Health Plan Considerations for Specialty & Infusion Medications

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Prescription Drug Coverage

•    Arthritis Foundation: Rx for Access Toolkit ​

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FAQ Section

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•    “Can you tell me which plan to choose?” → No, but we can share questions and resources to help you decide. 
•    “What if I don’t send my insurance update in time?” → It may cause delays or higher out-of-pocket costs for medications, infusions, or procedures. 
•    “What if I need help comparing plans?” → Contact your state’s SHIP program for free, unbiased guidance.

1.    Health Plan Considerations for Specialty & Infusion Medications​

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