PREMIUM

​

The amount you pay for your health insurance 

every month. 

​

​

​

​

The amount you pay for covered health care services before your insurance plan started to pay. Out-of-network services and cash services do not apply to your deductible. 

DEDUCTIBLE

​

COPAY

A fixed amount ($20, for example) you pay for a covered health care service (office visit or procedure) after you've paid your deductible. 

​

​

​

​

​

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits. The out-of-pocket limit doesn't include: Your monthly premiums.

​

MAX OUT OF

POCKET

​

COINSURANCE

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.

​

​

​

​

​

Your insurance has approved the prescription or service. This does not mean the cost is covered at 100%. Your cost varies based on your specific insurance contract, deductible and coinsurance. 

COVERED

RX TIER

Under your insurance plan, the prescription medicines available to you are split into tiers, which then determine your cost. Medicines are typically placed into 1 of 5 tiers—from Tier 1 (generics) to Tier 5 (highest-cost medicines)—depending on their strength, type or purpose.

PRIOR AUTH

Prior authorization is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage. Your provider will provide details of the treatment/prescription to the insurance company, including previous treatments, OTC medications, prescriptions and results. If the result is favorable, it does not ensure that the treatment will be covered at 100%. This is a time-consuming process and should be reserved for medically necessary services or prescriptions that have no lower cost equivalent.