Glossary of Terms
The percentage you pay for the cost of covered health care services after you’ve met your deductible. For example, if the coinsurance under your plan is 20%, you would pay 20% of the cost of the service and your insurance would pay the remaining 80%.
A predetermined dollar amount you pay for visits to the doctor, prescriptions and other health care services (as specified by your plan).
The amount of money you need to pay out-of-pocket before your insurance begins contributing money to your health care costs (except where copays apply).
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by the health plan. This is how much you will pay when you fill a prescription.
Generic – Lowest Cost
This tier is composed of non-brand and some low-cost brand drugs. Generics have the same active ingredients as brand-name drugs. The FDA expects these generics to work the same way as the original brand drugs.
Preferred Brand – Mid-range Cost
These are brand-name drugs that are listed on the plan’s formulary (list of preferred prescription drugs).
Non-preferred Brand – Highest Cost
These are brand-name drugs that are not included on the plan’s formulary (list of preferred prescription drugs).
Specialty Drugs are a recent designation of pharmaceuticals that are classified as high cost, high complexity and/or high touch. Specialty drugs are often biologics—“drugs derived from living cells” that are injectables or infused (although some are oral medications).
A statement of health that helps insurance underwriters evaluate the risk factor of an application.
The amount up to which evidence of insurability (EOI) is not needed to be approved for coverage.
A group of doctors, hospitals, labs, and other providers that your health insurance contracts with so you can make visits at a pre-negotiated (and often discounted) rate.
The most you pay each year out-of-pocket for covered expenses. Once you’ve reached the out-of-pocket maximum, the health plan pays 100% for covered expenses for the remainder of the year.