KEY TERMS
BRAND NAME PRESCRIPTION DRUG
A prescription drug that is sold under a trademarked name . An equivalent generic drug may or may not be available at lower cost , depending on whether the patent on the brand name drug has expired .
COPAY
A flat dollar amount you pay for a medical service .
COINSURANCE
The percentage of the charges you are responsible for paying . For example , the plan pays 70 % and you pay 30 %.
DEDUCTIBLE
This is the amount you pay before your plan begins covering expenses not subject to a copay .
EXPLANATION OF BENEFITS
The statement you receive from your insurance company detailing how much the provider billed , how much ( if any ) the plan paid , and the amount that you owe the provider ( if any ).
GENERIC PRESCRIPTION DRUG
A prescription drug made and distributed after the brand name drug patent has expired , and available at a lower cost than brand name prescriptions .
OUT-OF-POCKET ( OOP ) MAXIMUM
The most you pay in a calendar year for covered medical services . Once the OOP maximum is met , the plan will pay 100 % of the allowed amount for the remainder of the calendar year for covered services .
IN-NETWORK
Services from a provider or facility that is contracted with the insurance company . In-network providers agree to accept set fees for covered medical services and not bill you for any amounts over those fees . In-network providers also agree to bill the insurance company directly , so you will not have to pay up front and submit your own claims to the insurance company .
OUT-OF-NETWORK
Services from a provider or facility that is not contracted with the insurance company . If you receive services out-of-network , then you will typically have a higher coinsurance and you will be responsible for the difference between the provider ’ s billed charge and the allowable charge .
PREVENTIVE CARE
Measures taken to prevent diseases . This includes routine cancer screenings , exams and certain drugs and immunizations . Most preventive care is covered-in-full by the plan , with no cost to you .
Prepared by Gallagher for the Employees of The Suquamish Tribe 29