If you have a serious injury or health event, we suggest you call 9-1-1 or visit the nearest hospital Emergency Room.
A Network is the facilities, providers, and suppliers your health insurer has contracted with to provide health care services.
Contact your insurance company to find out which providers are “in network.” These providers may also be called “preferred-providers” or “participating providers.”
If a provider is “out of network” it may cost you more to see them. They are not contracted with your health insurer.
A deductible is the amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay.
Co-insurance is your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service. You pay co-insurance plus any deductibles you owe.
An Out-of-network Coinsurance is the percent you pay of the allowed amount covered health care services to providers who don’t contract with your health insurance or plan. They are usually higher than in-network co-insurances.
A Copayment or copay is an amount you may be required to pay as your share of the cost for a medical service or supply. It is usually a set amount rather than a percentage.
An Out-of-network Copayment is a fixed amount you pay for covered health care services from providers who don’t contract with your health insurance plan. They are usually higher than in-network copayments.
A Premium is the amount that must be paid for your health insurance plan. You or your employer pay it monthly, quarterly or yearly. It is not included in your deductible, copayment, or your co-insurance. If you don’t pay your premium, you could lose your coverage.
Out-of-pocket maximum is the most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential benefits. This limit includes deductibles, co-insurance, copayments, or similar charges.
Explanation of Benefits (or EOB) is a summary of health care charges that your health plan sends you after you see a provider or get a service. It is not a bill.
Excluded Services are health care services that your health coverage or plan doesn’t pay for.
Formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
A Preauthorization is a decision by your health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval, or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency.
A Primary Care Provider is the doctor you see first for most health problems. In many plans you must see your primary care provider before you see any other health care provider.
A Specialist is a physician who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.