Brand-Name Drug
A drug sold by a drug Company under a specific name or trademark that is protected by a patent. Brand-name drugs tend to be more expensive than generic drugs.
Calendar Year Maximum
The most the dental plan will pay for your and your family’s expenses in a given year. If you have expenses beyond this maximum, you are responsible for paying them.
Carrier or Insurer
The companies we have partnered with to provide benefits, such as Blue Cross Blue Shield (BCBS) of Massachusetts and Kaiser for medical coverage. It is important to understand that these carriers (not the Company) determine which services are eligible for coverage, the coverage level, and the plan rules and regulations.
Claim
An expense you incur that the plan shares in the cost of.
Coinsurance
Your share of the costs of a covered healthcare service, calculated as a percentage. You pay coinsurance plus any deductibles you owe. The health plan pays the rest of the allowed amount. For example, once you reach your deductible on the Consumer Choice Plan, you would pay 10% of the cost for a specialist office visit (10% coinsurance).
Copay
A fixed amount you pay for a covered service under a plan, usually when you receive the service. The amount can vary by the type of service. For example, you might need to pay a $20 copay when you visit an urgent care clinic.
Deductible
The amount you pay for covered healthcare services (other than preventive services) before the plan begins to pay. For example, Employee Only coverage through the Consumer Choice Plan has a $1,500 in-network deductible. So an individual would pay $1,500 out-of-pocket for any in-network services or supplies received. Once they satisfy the deductible, the plan begins paying a percentage of the cost, and the individual’s cost is calculated as coinsurance. (In this example, the Health Savings Account is available to help you pay the cost of your deductible using your own contributions and Company contributions to the account.)
Visit the Medical & Prescription Drug Coverage page > Comparing Coverage > Understanding How the Family Deductibles and Out-of-Pocket Maximums Work for examples of how deductibles work.
Eligible Expenses
The services and supplies eligible for plan coverage under your medical plan option. The service or supply must be recommended by a physician and must be essential for the necessary care and treatment of an injury or sickness. Those fees cannot exceed the allowed amount for out-of-network services.
Formulary
A list of drugs covered by the plan. These drugs are selected by the insurer based on their cost effectiveness.
Generic Drug
An alternative form of a brand-name drug that has been shown to be equally effective while also being less costly. For example, Sertraline is the generic drug version of the brand-name drug Zoloft.
Health Maintenance Organization (HMO)
A plan that offers coverage for services received from a specific network of providers associated with the plan. Participants pay for their share of the cost of services in the form of copays, and referrals are required for certain types of care. For example, we offer a Kaiser HMO to employees who live in certain California zip codes.
In-Network Coverage or In-Network Provider
A doctor, hospital, or other provider that has agreed to accept certain negotiated rates determined by the carrier. Note: The medical, dental, and vision plans have different provider networks.
Non-Formulary Drug
A drug not included as part of the plan’s list of covered drugs.
Out-of-Network Coverage or Out-of-Network Provider
A doctor, hospital, or other provider that has not agreed to accept certain negotiated rated, as determined by the carrier. If you go to an out-of-network provider, you generally pay more out of pocket.
Out-of-Pocket Maximum (OOP)
The maximum amount you must pay in a calendar year for certain eligible expenses. The out-of-pocket (OOP) maximum protects you from unbearable financial burdens by capping the total amount you will have to spend on your healthcare each year.
Visit the Medical & Prescription Drug Coverage page > Comparing Coverage > Understanding How the Family Deductibles and Out-of-Pocket Maximums Work for examples of how out-of-pocket maximums work.
Pre-Admission Certification/Prior Authorization
Pre-Admission Certification/Prior Authorization for hospital admissions and certain outpatient surgical and diagnostic procedures is required to receive care. You must obtain Pre-Admission Certification and/or Prior Authorization for certain types of care under the medical plan options to avoid a reduction in or denial of benefits for that care. Network providers generally coordinate Pre-Admission Certification/Prior Authorization on your behalf, but it is your responsibility to make sure it is obtained. For more information, contact Included Health at 1-833-938-9948 or visit includedhealth.com/Benefits4Me — or, if you are covered by the Kaiser HMO Plan, visit kaiserpermanente.org.
Preferred Provider Organization (PPO) Plan
A plan that offers in- and out-of-network coverage to its participants. Members pay for the cost of services through a mix of copays and coinsurance. Referrals are not required.
Premium
The amount that you pay into a plan to have coverage. This is sometimes referred to as a contribution.
Preventive Care
Services designed to prevent or detect illness before the condition develops or becomes more severe. All of the Company’s plans cover preventive care at 100%, according to age and frequency limits. For example, an annual physical with your primary care provider (PCP) is considered preventive care.
Referral
A written order from your primary care doctor for you to see a specialist or get certain medical services. If a referral is required and you don’t get one, the carrier may not cover the services.