Page 25 - Winsight 2021 Benefit Guide

Glossary

• Brand preferred drugs – A drug with a patent and • In-network – A designated list of health care providers
trademark name that is considered “preferred” because it (doctors, dentists, etc.) with whom the health insurance
is appropriate to use for medical purposes and is usually provider has negotiated special rates. Using in-network
less expensive than other brand-name options. providers lowers the cost of services for you and the
• Brand non-preferred drugs – A drug with a patent and company.
trademark name. This type of drug is “not preferred” and is • Inpatient – Services provided to an individual during an
usually more expensive than alternative generic and brand overnight hospital stay.
preferred drugs. • Mail Order Pharmacy – Mail order pharmacies
• Calendar Year Maximum – The maximum benefit generally provide a 90-day supply of a prescription
amount paid each year for each family member enrolled medication for the same cost as a 60-day supply at a
in the dental plan. retail pharmacy. Plus, mail order pharmacies offer the
• Coinsurance – The sharing of cost between you and convenience of shipping directly to your door.
the plan. For example, 80 percent coinsurance means • Out-of-network – Health care providers that are not
the plan covers 80 percent of the cost of service after in the plan’s network and who have not negotiated
a deductible is met. You will be responsible for the discounted rates. The cost of services provided by out-
remaining 20 percent of the cost. of-network providers is much higher for you and the
• Copay – A fixed amount (for example $15) you pay for company. Additional deductibles and higher coinsurance
a covered health care service, usually when you receive will apply.
the service. The amount can vary by the type of covered • Out-of-pocket maximum – The maximum amount you
health care service. and your family must pay for eligible expenses each
• Deductible – The amount you have to pay for covered plan year. Once your expenses reach the out-of-pocket
services before your health plan begins to pay. maximum, the plan pays benefits at 100% of eligible
• Elimination Period – The time period between the expenses for the remainder of the year. Your annual
beginning of an injury or illness and receiving benefit deductible is included in your out-of-pocket maximum.
payments from the insurer. • Outpatient – Services provided to an individual at a
• Flexible Spending Accounts (FSA) – FSAs allow hospital facility without an overnight hospital stay.
you to pay for eligible health care and dependent care • Primary Care Provider (PCP) – A doctor (generally a
expenses using tax-free dollars. The money in the family practitioner, internist or pediatrician) who provides
account is subject to the “use it or lose it” rule which ongoing medical care. A primary care physician treats a
means you must spend the money in the account wide variety of health-related conditions.
before the end of the plan year. • Reasonable & Customary Charges (R&C) –
• Generic drugs – A drug that offers equivalent uses, doses, Prevailing market rates for services provided by health
strength, quality and performance as a brand-name drug, care professionals within a certain area for certain
but is not trademarked. procedures. Reasonable and Customary rates may
• Health Savings Account (HSA) – An HSA is a personal apply to out-of-network charges.
health care account for those enrolled in a High • Specialist – A provider who has specialized training
Deductible Health Plan (HDHP). You may use your HSA in a particular branch of medicine (e.g., a surgeon,
to pay for qualified medical expenses such as doctor’s cardiologist or neurologist).
office visits, hospital care, prescription drugs, dental • Specialty drugs – A drug that requires special handling,
care, and vision care. You can use the money in your administration or monitoring. Most can only be filled
HSA to pay for qualified medical expenses now, or in the by a specialty pharmacy and have additional required
future, for your expenses and those of your spouse and approvals.
dependents, even if they are not covered by the HDHP.
• High Deductible Health Plan (HDHP) – A qualified
High Deductible Health Plan (HDHP) is defined by the
Internal Revenue Service (IRS) as a plan with a minimum
annual deductible and a maximum out-of-pocket limit.
These minimums and maximums are determined
annually and are subject to change.

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