Allowed amounts
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.

In-network benefits
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.

Out-of-network benefits
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.

Out-of-pocket maximum
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.

Specialty drugs
High cost, scientifically engineered drugs that are usually injected or infused.