Glossary
Allowable Amount - The maximum amount determined by the health plan to be eligible for consideration of payment for a particular service, supply or procedure.

Allowable Charge - The maximum amount a health plan will reimburse a doctor or hospital for a given service.

Annual Deductible - The amount of eligible expenses you are required to pay annually before reimbursement by your health plan begins.

Annual Limit - An insurance plan may limit the dollar amount it will pay during one year for a certain treatment or service, or for all benefits provided in a year.

Annual Out-of-Pocket - The maximum amount, per year, you are required to pay out of your own pocket for covered health care services.

Coinsurance - A percentage of an eligible expense that you are required to pay for a service covered by your health plan.

Coordination of Benefits (COB) - An arrangement where, if you or your dependents are covered under more than one group health plan, the plans work together to coordinate reimbursement for the medical services you received.

Copayment - A fixed dollar amount you are required to pay for a covered service at the time you receive care.

Covered Service - A service that is covered according to the terms in your health care policy.

Deductible - A fixed amount of the eligible expenses you are required to pay before reimbursement by your health plan begins.

Dependent - A person, other than the member/subscriber (generally a spouse or child), who receives health care coverage under the member's/subscriber's policy.

Drug Formulary - A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a plan's prescription drug list are automatically covered under that plan.

Exclusions - Specific medical conditions or circumstances that are not covered under a health plan.

Explanation of Benefits (EOB) - The form sent to you after a claim has been processed by your health plan. The EOB explains the actions taken on the claim such as the amount paid, the benefit available, and reasons for denying payment and the claims appeal process.

Generic Substitute - A prescription drug that is the generic equivalent of a drug listed on your health plan's formulary.

In-Network - Covered services provided or ordered by your primary care physician (PCP) or another network provider referred by your PCP.

Inpatient Services - Services provided when a member/subscriber is registered and treated as a bed patient in a health care facility such as a hospital.

Maximum Allowance - A fixed amount that providers agree to accept as payment in full for a particular covered service.

Out-of-Network - Services not provided, ordered or referred by your primary care physician (PCP).

Out-of-Pocket Maximum - The maximum amount you have to pay for eligible expenses under your health plan during a defined benefit period.

Outpatient Services - Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.

Pre-Determination - The process by which a member/subscriber or their primary care physician (PCP) notifies the health plan, in advance, of plans for the member/subscriber to undergo a course of care such as a hospital admission or a complex diagnostic test.

Preferred Drug List - A list of commonly prescribed drugs (also known as a prescription drug list). Not all drugs listed in a health plan's prescription drug list are automatically covered under that plan.