| What is a Copay? |
A copay is a flat dollar amount you pay for a service; typically these are for doctor visits (family, primary care physician (PCP), pediatrician, etc…) or prescriptions. |
| Do I have to pay my deductible first before the copay kicks in? |
The copay for a doctor visit is all you pay for the doctor's charge; if the doctor has more extensive stuff done for you (X-Rays, lab work, etc...), than the deductible will aplly to those things; your deductible DOES NOT need to be met before the copay applies for the doctor charge. |
| What is a Deductible? |
Deductible is the amount you pay first for many services (per calendar year); typically applies to hospital stays, emergency room, outpatient surgeries, x-rays, diagnostic testing, etc… REMEMBER – when there’s no copay, deductible usually applies and deductible means YOU PAY FIRST; on our exhibits - 1st number in sequence is per person; 2nd number in sequence is per family. |
| What is a Coinsurance? |
Your portion of the bill to pay after the deductible is met until the bill is paid or your Annual Max. is met; anywhere you see coinsurance, deductible applies first. |
| What is a the Annual Max? |
Maximum paid in calendar year (including deductible); 1st number = per person; 2nd number = per family. |
| How are Emergency Room visits covered? |
Deductible and coinsurance apply, unless otherwise stated |
| Please explain the prescription benefit |
When three numbers are present ($10/$20/$30), the 1st number is for generic drugs, the 2nd number is for brand drugs on the company’s formulary and the 3rd number is for drugs NOT on the company’s formulary; when four numbers are present ($15/$30/$60/25%) the 1st number is for generic drugs, the 2nd number is for brand drugs on the company’s PREFERRED formulary, the 3rd number is for brand drugs NOT on the company’s PREFERRED formulary and the 4th number is for drugs NOT on the company’s formulary. |
| What is a Formulary? |
An insurance company’s defined list of prescription drugs that they cover. |
| What is a PPO? |
PPO stands for "Preferred Provider Organization". It simply means a defined list of doctors or hospitals (In Network) that a member needs to use to get the best benefits and contracted rates; PPOs differ from HMOs as you don't need your Primary Care Physician to coordinate your care (or get an official referral). |
| What happens when I go "Out of Network"? |
Going to doctors or hospitals other than those “In Network” are considered “Out of Network”. Your deductible, coinsurance, Annual Max, etc… are usually higher. “Balance Billing” is also an issue. |
| What is balance billing? |
Balance billing is the amount of money a doctor or hospital can charge you over and above UCR (Usual, Customary & Reasonable). When you go "Out of Network", there are no pre-negotiated rates between the insurance company and medical provider. Insurance companies will pay medical providers based upon some percentage of UCR. When you stay "In Network", the medical providers have agreed, by contract, not to charge you anything more than the pre-negotiated rate, regardless of what their actual billed charges may be. Going "Out of Network" does not give you this protection. |
