Glossary

Annual Deductible — The amount you are required to pay annually before reimbursement by your health care benefits plan begins.

Annual Out-of-Pocket Maximum — The maximum amount, per year, you are required to pay out of your own pocket for covered health care services after the deductible is met.

Claim — An itemized bill for services that have been provided to a subscriber, a subscriber's spouse or dependents.

Claim Form — A form you or your doctor fill out and submit to your health care benefits plan for payment.

Contracting Hospital — A hospital that has contracted with a particular health care plan to provide hospital services to members of that plan.

Copayment — A fixed dollar amount you are required to pay for covered services at the time you receive care.

Deductible — A fixed amount you are required to pay before health care benefits begin.

Drug Formulary — A list of preferred drugs chosen by a panel of doctors and pharmacists. Both brand and generic medications are included on the formulary.

Explanation of Benefits (EOB) — An EOB is created after a claim payment has been processed by your health care plan. It explains the actions taken on a claim such as the amount that will be paid, the benefit available, reasons for denying payment and the claims appeal process. EOBs are available both as a paper copy and online.

Generic Drug — A prescription drug that is the generic equivalent of a brand name drug listed on your health plan's formulary and costs less than the brand name drug.

Identification Number/ID Number — A unique number that identifies you as a member of a particular health care plan (also known as a member ID or a subscriber ID).

In-Network — Services provided or coordinated by your primary care physician (PCP) and paid at a higher benefit level.

Inpatient Services — Services provided when a member is registered as a bed patient and is treated as such in a health care facility such as a hospital.

Member — The person to whom health care coverage has been extended by the policyholder (generally their employer) or any of their covered family members. Sometimes referred to as the insured or insured person.

Network — The group of doctors, hospitals and other medical care professionals that a managed care plan has contracted with to deliver medical services to its members.

Out-of-Network — Services provided by doctors and hospitals who have not contracted with your health plan.

Out-of-Pocket Maximum — The maximum amount you have to pay for expenses covered under your health care plan, after any deductible is met, during a defined benefit period.

Plan Type — The type of health care plan in which you are enrolled (for example, HMO, PPO or POS).

Pre-Certification — The process by which a plan member or their doctor notifies the plan, before the member undergoes a course of care such as a hospital admission or a complex diagnostic test.

Participating Provider Option (PPO) — A health care plan that supplies services at a higher level of benefits when members use contracted health care professionals. PPOs also provide coverage for services rendered by health care professionals who are not part of the PPO network, however the plan member generally shares a greater portion of the cost for such services.

Prescription Drugs — Drugs and medications that, by law, must be dispensed by a written prescription from a licensed doctor.

Prescription Drug List — A list of commonly prescribed drugs (also known as a drug formulary). Not all drugs listed in a plan's prescription drug list are automatically covered under that plan.

Specialist — A health care professional whose practice is limited to a certain branch of medicine such as specific procedures, age categories of patients, specific body systems or certain types of diseases.