Wondering what a term means? Find it here.
Brand Name
A more expensive prescription drug for which there is an active patent. (A patent is a time-sensitive right to market a drug under a certain name.)
Coinsurance
The percentage of costs you pay for eligible expenses after you meet the deductible.
Coverage Level
A benefit level that determines how services are covered.
Deductible
What you pay out of your own pocket before your insurance begins to pay a share of your costs. How the deductible works depends on your coverage level. Out-of-network charges do not count toward your in-network annual deductible. They only count toward your out-of-network deductible.
EOB
Also known as an Explanation of Benefits. An EOB shows the claim filed by your health care professional, what was paid, and what your portion of the payment was or will be. Your insurance carrier provides the EOB. It’s not a bill.
Formulary
A list of generic and brand name drugs that are approved by the Food and Drug Administration (FDA) and are covered under your prescription drug plan. You should make sure your medication is on the formulary of the medical insurance carrier you choose.
Generic
Medications that have been approved by the FDA as safe and effective. These medications contain the same active ingredients in the same amounts as brand name products. Generics may be different in color, shape, or size from their brand name counterparts. Your physician may substitute a generic for a brand name drug to save you money.
HMO
Health Maintenance Organization (HMO) options offer care through a network of doctors and hospitals. All of your care generally must be provided through the HMO network and coordinated through the HMO primary care physician (PCP) you select when you enroll. Except in emergencies, your care is usually covered only if it’s coordinated by your PCP. There’s no coverage for out-of-network care.
Network
A group of health care providers that offer services to participants in a health plan at a negotiated, discounted cost. You’ll save money if you use doctors inside your carrier’s network.
Out-of-Pocket Maximum
The most you have to pay for covered medical services in a year. Generally, it includes any applicable deductible, copayments, and/or coinsurance. How the out-of-pocket maximum works depends on your coverage level. Out-of-network charges do not count toward your in-network annual out-of-pocket maximum. They only count toward your out-of-network out-of-pocket maximum.
Payroll Contribution
The amount deducted from your paycheck on a pre-tax basis to cover your share of health care benefit costs.
Pharmacy Benefit Manager
The insurance carrier or third-party administrator who manages your retail and mail-order prescription drug benefit.
PPO
A Preferred Provider Organization, or PPO, is a type of medical plan that uses a network of physicians, hospitals, and other health care providers that have agreed to provide care at negotiated prices. You can also go to out-of-network providers, but you’ll pay more.
Preventive Care
Annual physicals, wellness screenings, immunizations, well-woman exams, well-baby exams, and more. In-network preventive care is 100% covered without having to pay your deductible.
Reasonable and Customary
The normal charge made by a licensed practitioner in a specific area for a specific service. It doesn’t exceed the normal charge made by most providers in the area where the service is provided.
Traditional Deductible
Once a covered family member meets the individual deductible, your insurance will begin paying benefits for that family member.
Traditional Out-of-Pocket Maximum
Once a covered family member meets the individual out-of-pocket maximum, your insurance will pay the full cost of covered charges for that family member.
True Family Deductible
The entire family deductible must be met before your insurance will pay benefits for any covered family member.
True Family Out-of-Pocket Maximum
The entire family out-of-pocket maximum must be met before your insurance will pay the full cost of covered charges for any covered family member.