Common Terms You'll Need to Know

Coinsurance: the percentage of health care costs you are responsible for paying, typically after your deductible is met

Copay: a fixed dollar amount you must pay with your own money for medical services, like office visits or prescription drugs

Deductible: the amount of money you must pay each year – with your own money – before the insurance company begins paying benefits

Formulary drug list: a list of brand name and generic prescription drugs and over-the-counter drugs covered by your health insurance plan

High-Deductible Health Plan (HDHP): a health insurance plan with lower premiums and higher deductibles than a traditional health plan

Maximum Allowable Charge (MAC): the maximum dollar amount BlueCross BlueShield of Tennessee will pay a doctor, hospital or other health care provider for a covered medical service

Network: a group of doctors, hospitals and other health care providers contracted to provide services to insurance companies' customers for less than their usual fees

Out-of-pocket maximum: the total amount you pay with your own money – or out of your own pocket – in a year

Pre-existing condition waiting period: the length of time that you will not receive benefits for treatment of any health condition that you already have as of the effective date of your policy

Preferred Provider Organization (PPO): a network of doctors, caregivers and medical facilities that agree to provide health care services to our members at a lower cost; members get the most from their PPO plan when network providers are used

Premium: the monthly payment made for an insurance policy

Prescription drug benefits (Rx): the type of benefits provided for the purchase of drugs prescribed by a physician that are not available over the counter

Primary Care Practitioner (PCP): a health care provider specializing in family practice, internal medicine, general practice, pediatrics, obstetrics or gynecology, or a physician assistant or nurse practitioner

Prior authorization: getting approval for certain medical procedures before you are treated

Qualifying event: a change in circumstances (like marriage, divorce, losing employer-sponsored health coverage) that would allow a member to change plans or add optional maternity coverage

Rider: an amendment to your policy that either adds coverage (like a maternity benefits rider) or specifies a particular condition that won't be covered (a benefit exclusion rider)

Schedule of Benefits: a complete overview of the covered benefits your plan provides

Wellness benefit: coverage for routine services and preventive visits, like cancer screenings, mammograms and physicals


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