Benefit Guide - People

MEDICAL TERMINOLOGY

Calendar Year Maximum Total dollar amount a plan pays during a calendar year toward the covered expenses of each person enrolled. Claim A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered. Coinsurance The percentage of costs of a covered health care service you pay (30%, for example) after you've paid your A predetermined (flat) fee an individual pays for health care services, in addition to what the insurance covers. Deductible The amount you pay for covered health care services before your insurance plan starts to pay. Check your carrier certificates to confirm how your plan satisfies the family deductible. Generic Drugs These drugs are usually most cost effective. Generic drugs are chemically identical to their brand name counterparts. Purchasing generic drugs allows you to pay a lower out - of - pocket cost. In - Network A doctor or facility providing your care has a negotiated a contract rate with your health insurance company. You may not be balanced billed for amounts over the coinsurance. deductible. Copayment

Network A group of healthcare providers, including dentist, physicians, hospitals, and other healthcare providers, that agrees to accept pre determined rates when serving members. recommended formulary list. These drugs are usually more expensive than drugs found on the formulary. You still may purchase these, but at a higher out - of - pocket cost Out - of - Network A doctor or facility providing your care does not have a contract with your health insurance company. You may be balanced billed for amounts over the coinsurance. Out - of - Pocket Maximum/Limit The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. Non - covered services or amounts over the U&C are not applied to your out - of - pocket maximum. Preferred Brand Drugs The brand is formulary approved, recommended list of brand name medications. Drugs on this list are available to you at a lower cost than drugs that do not appear on the list. Primary Care Physician (PCP) A physician who directly provides or coordinates a range of health care services for a patient. Non– Preferred Brand Drugs These drugs are not on the

Provider Any type of healthcare professional or facility that provides care under your plan. Specialist A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non - physician specialist is a provider who has more training in a specific area of health care. Specialty Drugs Prescription medications that require special handling, administration, or monitoring. These drugs may be used to treat complex, chronic, and often An occurrence that qualifies the subscriber to make an insurance coverage change outside of open enrollment Usual and Customary Allowance Usual and customary allowance is the amount of money that a particular acceptable range of payment for a specific health - related service or medical procedure. Virtual Visits A consultation between you and a provider who is performing a clinical medical or behavioral health service by two - way audiovisual or telephone calls. costly conditions. Qualifying Event health insurance company determines if the normal or

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