Summary of Benefits & Services
Glossary of Terms
A percentage of fees paid for services. For example, after your annual deductible is met, you pay 20% and the plan pays 80% of your claim costs up to the out-of-pocket maximum.
The set amount you pay directly to the provider when you receive certain services. For example, the $30 you pay each time you visit your Primary Care Physician or the $30 you pay for generic drugs.
The amount you pay each year before the plan begins to pay for expenses.
This protects you financially. The out-of-pocket maximum limits the amount you have to pay (out of your own pocket) each year for covered medical expenses.
Primary Care Physician (PCP)
This is your main doctor. They are your first point of contact when you need care. Your PCP also coordinates other care as needed (for example, if you need a specialist).
Usual and Customary Fees
The amount insurance pays based upon the average cost of the service provided for the area.
The list of medications, prescription or generic that your insurance plan will pay for. A formulary may also say how much you pay for each drug.
Services or supplies that meet acceptable standards of medical practice and are essential for the diagnosis and treatment of your health condition.
amount you have to pay (out of your own pocket) each year for covered
Out Of Pocket Costs
These costs aren’t covered by your health plan. Deductibles, coinsurance, copayments and some supplies or services are examples.
The amount deducted from your paycheck for coverage.
Services that prevent illness or detect illness at an early stage, such as flu shots and screening mammograms.
Some conditions require the care of a doctor with narrower but deeper skills than a primary care physician can offer. A cardiologist, for example, knows more about the heart; a nephrologist knows more about kidney problems.
Care for an illness, injury or condition serious enough for immediate care but not so severe as to require emergency room care. Visiting an urgent care center may be cheaper than the ER. However, most plans offer only partial payment, requiring either a copay or coinsurance.