Copay

A fixed amount ($20, for example) you pay for a covered health care service.

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Deductible

The amount you owe for covered health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve paid $1,000 for covered services. Some plans pay for certain health care services before you’ve met your deductible.

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Dental Coinsurance

The amount the insurance company pays for a dental claim, up to the annual maximum.

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HSA

Under the Health Savings Account (HSA) medical plan, when obtaining care, you will pay the contracted rate for covered services until you reach a set amount known as your deductible. After you reach your deductible, you’ll start paying less – just a copay or a percentage of the charges (coinsurance) for the rest of the year, or until you reach your out-of-pocket maximum.  Members of this plan are entitled to open up a Health Savings Account (HSA) to set aside funds to help pay for services rendered on this plan.

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In-Network

An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates. An out-of-network provider is not contracted with the health insurance plan.

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Medical Coinsurance 

The amount you are required to pay for a medical claim, apart from any co-payments or deductibles.

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Out-of-Network

This phrase usually refers to physicians, hospitals or other health care providers who are considered non-participants in an insurance plan (usually an HMO or PPO).

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Out-of-Pocket Maximum

This the most you’ll have to pay during a policy period (usually a calendar year) for health care services. Once you’ve reached your out-of-pocket maximum, your plan begins to pay 100 percent of the allowed amount for covered services (in-network).

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PPO

Preferred Provider Organization (PPO) plans are health care plans contracted with a network of medical providers. PPO members have the option to select a preferred provider and only pay their deductible and office visit copay, or select an out-of-network provider and pay a slightly higher amount. PPO members also do not need to choose a primary care physician (PCP) and do not require referrals when going to a specialist.

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Prescriptions: Brand

A drug that has a trade name and is protected by a patent (can be produced and sold only by the company holding the patent).

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Prescriptions: Generic

A generic drug is a chemically equivalent, lower-cost version of a brand-name drug. A brand-name drug and its generic version must have the same active ingredient, dosage, safety, strength, usage directions, quality, performance and intended use as the brand-name drug.

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Prescriptions: Non-Formulary

Non-formulary drugs are not on the insurance policy’s list of preferred drugs.  Therefore, non-formulary drugs will cost the members more money than formularies (Generic and Brand).

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Preventive Services

Routine health care that includes checkups, patient counseling, and screenings to prevent illness, disease and other health-related problems.

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