Not sure what some of the terms on this website mean?
You’re not alone! In many ways, healthcare and health insurance have their own language. We’ve shared some of the most commonly used words and their definitions here.
What you pay every month to have coverage
Amount you must pay each year before insurance starts paying for certain services (typically the ones where you pay a percentage instead a flat dollar amount)
Percentage you pay for covered expenses after you meet your deductible
Fixed dollar amount you pay for certain services
Most you’ll pay before plan pays 100% for remainder of the calendar year
A Preferred Provider Organization or PPO is a type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
A Health Maintenance Organization or HMO has its own network of doctors, hospitals, and other healthcare providers who have agreed to accept payment at a certain level for any services they provide. HMOs often provide integrated care and focus on prevention and wellness. Typically, no coverage is offered for providers outside the HMO except in cases of emergency or if an HMO provider refers you to a specialist outside the HMO because the HMO does not offer that specialty.
A drug formulary is the list of prescription drugs (generic and brand name) that are covered by a pharmacy plan. A formulary is typically reviewed by a pharmacy’s internal committee (made up of physicians and other experts) and may change at any time based on new evidence or other factors.
FDA-approved generic medicines work in the same way and provide the same clinical benefit and risks as their brand-name counterparts. A generic medicine is required to be the same as a brand-name medicine in dosage, safety, effectiveness, strength, stability, and quality, as well as in the way it is taken.
Preferred (or formulary) drugs
These may include generic or brand-name medications that are on a list of prescription drugs covered by a prescription drug plan. Also called a drug list.
Non-preferred (or non-formulary) drugs
If a medication is “non-formulary,” it means it is not included on the insurance company’s “formulary” or list of covered medications. A medication may not be on the formulary because an alternative is proven to be just as effective and safe but less costly.
Specialty drugs sometimes require special handling and administration (typically injection or infusion), and patients using a specialty drug may need careful oversight from a healthcare provider who can watch for side effects and ensure that the medication is working as intended. They are often high-cost prescription medications used to treat complex, chronic conditions like cancer, rheumatoid arthritis, and multiple sclerosis.
Trust coverage operates on a calendar year basis from January 1 – December 31.
Doctors, other healthcare providers, pharmacies, and facilities contract with insurance companies to become an “in-network” provider. If you go to a provider who is in your insurance company’s network, you will typically pay less than if you go to an “out-of-network” provider who doesn’t have a contract with your insurance company. Don’t expect your healthcare provider to know what other providers are in your network. Check with your insurance plan if you are referred to another provider for services to verify they are in-network providers.
Doctors, other healthcare providers, pharmacies, and facilities that have not contracted with your insurance. In the case of a PPO, out-of-network providers are typically covered less and will cost you more out-of-pocket. In the case of an HMO, typically no coverage is offered for out-of-network providers (except in cases of emergency or if an HMO provider refers you to a specialist outside the HMO because the HMO does not offer that specialty). That means if you go to an out-of-network provider, you will be responsible for 100% of the cost.
Primary care provider
A primary care provider (PCP) sees patients for common things like colds and flu, headaches, back pain, etc. They also manage chronic conditions like high blood pressure, diabetes, obesity, anxiety, and depression. They can refer you to a specialist if you have a health issue that falls outside their scope. PCPs coordinate your care with other providers, so they have a complete picture of your healthcare needs.
Routine health care like screenings, flu shots, and annual checkups to prevent illnesses, disease, or other health problems. Covered preventive services from a participating provider are available at no cost to you.
Care where the purpose is to look for something specific like the cause of an illness or further investigation into the result of a preventive test or screening.