Definitions
Annual Deductible: the amount you pay out of pocket for covered services before the plan starts to pay.
Annual Out-of-Pocket Maximum: the most you pay each year in deductibles, coinsurance, copays, and any other covered out-of-pocket expenses. After you reach the maximum out-of-pocket, the plan pays 100 percent of eligible expenses for the remainder of the year.
Primary Care Physician Visits: PCP stands for Primary Care Physician. A doctor who is trained to provide a basic, comprehensive, routine level of health care. These physicians are specifically trained to help patients maintain good health, to identify and effectively treat routine health problems, and to refer patients to the appropriate specialist if a more serious problem is identified. Learn more about PCP.
Specialist: Providers whose practices are limited to treating a specific disease (e.g., oncologists who treat cancers), specific parts of the body (e.g., otolaryngologists who treat ear, nose and throat), or specific procedures (e.g., orthopedists who perform joint surgeries).
Outpatient Surgery/Procedures: Outpatient or ambulatory surgery refers to surgical and nonsurgical procedures performed on an outpatient basis in a hospital or freestanding ambulatory surgery center’s general operating rooms, and other specialized rooms such as endoscopy units and cardiac catheterization labs. To see a list of outpatient procedures requiring a copay, click here.
Preventive Care: Procedures and services provided by medical providers and other practitioners which are designed to prevent disease or arrest its development. To see a list of Preventive Care Guidelines, click here.
Generic: FDA-approved drugs containing the same active ingredients as their brand-name counterparts.
Formulary Brand: Preferred drugs that include select brand-name medications chosen for their clinical effectiveness, safety profiles, and/or lower costs.
Non-formulary Brand: Brand-name drugs not on the forumulary list because of safety, efficacy, and/or cost concerns.
