The discounted maximum amount that in-network medical providers or pharmacies are “allowed” to charge a plan member. This amount will be lower than what providers charge cash pay or out-of-network patients, due to the discount you get for using an in-network provider.
The member’s share of the cost of a covered service. For example, if a plan pays 80%, the member’s coinsurance is 20%.
A fixed amount paid for a covered service. For example $75 for urgent care.
The dollar amount of covered services an individual must pay to their provider each plan year before the plan starts paying on claims.
Benefits for covered services rendered by a network of physicians and hospitals who have contracted with Anthem. Users of in-network providers generally pay lower rates for services.
Any person covered under a plan, including the employee, a spouse or a child. Sometimes also referred to as enrollee or participant.
A group of physicians and hospitals who have contracted to provide medical services at a reduced rate per an agreement with an insurance company.
Benefits for covered services rendered by physicians and hospitals who are not contracted with Anthem. Generally, costs for out-of-network care will be higher.
The out-of-pocket maximum helps protect you from high medical bills. Once the health plan’s out-of-pocket maximum is reached, the plan pays 100% of covered charges for the remainder of the plan year. Deductible, coinsurance, and medical copay amounts all apply toward the out-of-pocket maximum (note that there is a separate out of pocket maximum for in-network prescription copays on the $500 Deductible Plan).
Preferred Provider Organization (PPO)
A Preferred Provider Organization is a medical plan that uses a network of contracted physicians and facilities to provide services at discounted rates. A PPO gives members the option of using providers outside the network; but with a separate deductible, and higher coinsurance and balance billing for charges in excess of the allowed amount.
High cost, scientifically engineered drugs that are usually injected or infused.