Annual or lifetime maximum: An upper limit on costs or services covered by a plan. For example, a plan may limit you to 60 days of occupational therapy or put a ceiling on the dollar amount of coverage it will provide over your lifetime.
Brand Name Prescription Drug or Medicine: A Prescription Drug which is protected by trademark registration.
Copayment (copay) or co-insurance: A dollar amount or percentage you're responsible for paying for your covered health services. You may have to pay a set amount every time you make an office visit, a different amount for lab work, and various amounts for different types of prescription drugs. You may have to meet a deductible before your copay or co-insurance kicks in.
Deductible: The amount you have to pay for covered medical services before your health plan starts chipping in. Your deductible amount may be very small or really quite large.
Elective Treatment: Treatment which is not medically necessary such as cosmetic surgery or procedures.
Exclusion: A health condition or circumstance not eligible for coverage under your health plan. What your plan doesn't cover is listed in the Certificate of Coverage for your benefits.
Explanation of benefits: Everytime you or your doctor files a claim with your insurance company, the policy holder gets an Explanation of Benefits, also known as an EOB or claims statement. The EOB explains how your health-benefits claim was processed. If you have questions about any information on the form, you should call immediately to resolve any issues.
Generic Prescription Drug or Medicine: A Prescription Drug that is not protected by trademark registration, but is produced and sold under the chemical formulation name.
HMO (Health Maintenance Organization): A plan in which you select a primary care physician (PCP) who coordinates your care and refers you to specialists when needed. If you get care from someone not in the network, expect to pay the full cost yourself unless you need care that no physician in the HMO network can provide.
Medical Provider: Licensed medical personnel that provides medical care including: Physician, Nurse Pracitioner, Physician's Assistant, or Specialist (including Gynecologist, Podiatrist, etc.).
Negotiated Charge: The maximum charge a Preferred Care Provider has agreed to make for a service or supply for the medical care.
Non-Preferred Care: A health care service or supply furnished by a health care provider that is not in your insurance company's network.
Non-Preferred Pharmacy: A pharmacy that provides prescription drugs that is not in your insurance company's network.
Out-of-pocket: Money you pay toward the cost of healthcare services. Expenses include deductibles, copayment, and co-insurance. Some plans put a cap on your out-of-pocket expenses. After you reach the out-of-pocket maximum, the health plan pays all of your covered costs.
POS (Point-of-Service): Almost a combination of an HMO and a PPO, with a POS you can choose to get care from both in-network and out-of-network physicians. In many POS plans, if you get a referral from your PCP, you don't pay as much as you do if you bypass your PCP.
PPO (Preferred Provider Organization): As with an HMO, you choose from doctors within your network, but you don't have to designate one doctor as your PCP. PPOs offer out-of-network coverage, though you have to pay a higher portion of the cost.
Preferred Care Provider (or Preferred Provider): A health care provider that has contracted to furnish services or supplies for a negotiated charge that is in the insurance company's network.
Preferred Pharmacy: A Pharmacy, including a mail order Pharmacy, which is party to a contract with the insurance company to dispense drugs to persons covered under the Policy, but only while the contract remains in effect.
Premium: The cost of an insurance plan.
Primary Care Physician (PCP): The physician that supervises, coordinates, and provides medical care to members of an HMO plan.
Reimbursement: A payment either to you or a health care professional for covered medical services.