Brand-Name Drugs
A drug with a patent and trademark name. Brand-name drugs may be included in any tier depending on cost, efficacy, safety and availability of alternate medications.
Calendar-Year Maximum
The maximum benefit amount paid each year for each family member enrolled in the dental plan.
Coinsurance
The sharing of cost between you and the plan. For example, 80% coinsurance means the plan covers 80% of the cost of service after a deductible is met. You will be responsible for the remaining 20% of the cost.
Copay
A fixed amount (for example $20) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Deductible
The amount you need to pay for covered services before your health plan begins to pay.
Elimination Period
The time period between the beginning of an injury or illness and receiving benefit payments from the insurer.
Embedded Deductible
Each person only needs to meet the individual deductible before the plan begins paying its share for that individual. (And, once two or more family members meet the family limits, the plan begins paying its share for all covered family members.)
Embedded Out-of-Pocket Maximum
Each person only needs to meet the individual out-of-pocket maximum before the plan begins paying its share for that individual. (And, once two or more family members meet the family limits, the plan begins paying its share for all covered family members.)
Flexible Spending Account (FSA)
An FSA allows you to pay for eligible health care or dependent care expenses using tax-free dollars. The money in the account is subject to the “use-it-or-lose-it” rule, which means you must spend the money in the account before the end of the plan year.
Generic drugs
A drug that offers equivalent uses, doses, strength, quality and performance as a brand-name drug, but is not trademarked. Generic drugs may be included in any tier depending on cost, efficacy, safety and availability of alternate medications.
Health Savings Account (HSA)
An HSA is a personal health care account for those enrolled in a High Deductible Health Plan (HDHP). You may use your HSA to pay for qualified medical expenses, such as doctor’s office visits, hospital care, prescription drugs, dental care and vision care. You can use the money in your HSA to pay for qualified medical expenses, now or in the future, for yourself, your spouse/domestic partner and dependents, even if they are not covered by the HDHP.
High Deductible Health Plan (HDHP)
A qualified High Deductible Health Plan (HDHP) is defined by the Internal Revenue Service (IRS) as a plan with a minimum annual deductible and a maximum out-of-pocket limit. These minimums and maximums are determined annually and are subject to change.
In-Network
A designated list of health care providers (doctors, dentists, etc.) with whom the health insurance provider has negotiated special rates. Using in-network providers lowers the cost of services for you and the company. Inpatient Services provided to an individual during an overnight hospital stay.
Mail-Order Pharmacy
Mail-order pharmacies generally provide a 90-day supply of a prescription medication for a lower cost than three, 31-day fills supplied at a retail pharmacy. Plus, mail-order pharmacies offer the convenience of shipping directly to your door.
Out-of-Network
Health care providers who are not in the plan’s network and who have not negotiated discounted rates. The cost of services provided by out-of-network providers is much higher for you and the company. Additional deductibles and higher coinsurance will apply.
Out-of-Pocket Maximum
The maximum amount you and your family must pay for eligible expenses each plan year. Once your expenses reach the out-of-pocket maximum, the plan pays benefits at 100% of eligible expenses for the remainder of the year. Your annual deductible is included in your out-of-pocket maximum.
Outpatient
Services provided to an individual at a hospital facility without an overnight hospital stay.
Primary Care Provider (PCP)
A doctor (generally a family practitioner, internist or pediatrician) who provides ongoing medical care. A primary care physician treats a wide variety of health-related conditions.
Reasonable & Customary Charges (R&C)
Prevailing market rates for services provided by health care professionals within a certain area for certain procedures. Reasonable & Customary rates may apply to out-of-network charges.
Specialist
A provider who has specialized training in a particular branch of medicine (e.g., a surgeon, cardiologist or neurologist).
Specialty Drugs
A drug that requires special handling, administration or monitoring. Most can only be filled by a specialty pharmacy and have additional required approvals.