How it worksSafetyHealth libraryOur mission Sign in Start a free consult
Pymander
Free consult

How do I find out what my insurance covers?

Updated Sep 3, 20261 min readAnswer
On this pageShort answer What to do Common questions Related questions Sources
Short answer

Start with the Summary of Benefits and Coverage - the standardized document every plan must provide, per HealthCare.gov - then the member portal for network and cost tools, and the formulary for drugs and prior-auth flags. For anything planned and expensive, call member services with a specific question and get a reference number.

Pymander is a free AI doctor, 24/7 by text, and can help.

How do I find out what my insurance covers? Ask our AI doctor - a straight answer in plain language, free, 24/7. Start a free consult Free · Private · 24/7
Coverage question? Text a free AI doctorStart a free AI doctor consult

What to do

1Find your SBCin the member portal - it is the plan in one standardized document.
2Search the formularybefore any new prescription is filled.
3Ask specific questions by phone:visits, copay, prior auth - and log the reference number.
4Get big-ticket answers in writingbefore the procedure, not after the bill.

Common questions

How do I find out what my insurance covers?

Coverage questions feel opaque because the answer lives in documents nobody shows you how to read. Start with the Summary of Benefits and Coverage - the SBC. Federal rules require every plan to give you one in a standard format, and HealthCare.gov explains it exists precisely so you can compare plans and understand benefits: it shows, in the same layout for every insurer, what you pay for a doctor visit, a specialist, an ER trip, drugs by tier, and what your deductible and out-of-pocket maximum are. For a specific service, go one level deeper: your insurer's member portal or app has your actual plan documents, the provider directory for network checks, and usually a cost-estimator tool. For medications, the document that matters is the formulary - the plan's drug list, tiered by price - searchable on the insurer's site; it also flags which drugs need prior authorization. For the stubborn cases, call the member services number on your card and ask the question in its most specific form: not do you cover physical therapy, but how many PT visits per year, at what copay, and do they need prior auth - and note the date, name, and reference number of the call. One habit worth building: before any planned procedure, get the answer in writing or by reference number, because the verbal yes is what you appeal with later. Pymander is a free AI doctor, 24/7 by text, and can help you read an SBC or plan the call.

About this page. Written and maintained by the Pymander Health team. Last updated September 3, 2026.

Questions about this?Start a free consult