Why the exact plan name matters
“We accept that insurance company” is not the same as “we participate in this exact plan and network.” A single insurer may offer several HMO, EPO, POS, or PPO networks. Coverage rules and out-of-network benefits can differ substantially by plan type.
Identify the plan
Write down the full plan name, network, plan ID, and proposed effective date. Save the Summary of Benefits and Coverage.
Check the insurer
Search the current directory, then call the insurer and record the date, representative, and reference number.
Check the provider
Call the doctor's office and facility separately. Ask about the exact plan, location, physician, and referral requirements.
Check every prescription
Confirm the formulary tier, estimated cost, prior authorization, step therapy, quantity limits, and pharmacy network.
What to verify
| Item | Where to check | Question to ask |
|---|---|---|
| Doctor or specialist | Insurer directory, insurer, and provider office | “Is this physician participating in this exact plan at this location?” |
| Hospital or facility | Insurer directory and facility | “Are both the facility and treating professionals participating?” |
| Prescription | Plan formulary and insurer | “What tier and utilization rules apply to this dose?” |
| Pharmacy | Insurer pharmacy directory | “Is this pharmacy preferred, standard, mail-order, or out of network?” |
| Coverage date | Enrollment confirmation | “On what date will coverage be active and usable?” |
What a broker can help with
A broker can help organize plan comparisons, locate directories and formularies, explain plan documents, and identify questions to ask. Provider participation, prescription coverage, eligibility, and benefits still need to be confirmed through official plan materials, the insurer, the provider, and the pharmacy.
Want help organizing the verification calls?
Bring the exact plan name and your provider and prescription list. Caden can help identify the directories, formularies and questions to use; the insurer, provider and pharmacy still make the controlling confirmations.
Do not send diagnoses, Social Security numbers or other sensitive medical information through basic email or contact forms. Review Caden’s broker methodology, licenses, and compensation disclosure.
Take the worksheet with you
Use the printable page while comparing plans or speaking with an insurer, doctor's office, pharmacy, employer, or broker.
Download the Verification Worksheet