Medical Plans
PDP
Terminology
Features
Miscellanous
100
Members in this plan do not need referrals and can choose to go out of network for a higher cost.
What is a PPO?
100
Drugs that are not on this list will not be covered.
What is a formulary?
100
Medical assistance from the government for low income individuals.
What is Medicaid?
100
Some examples of this include emergency services, urgently needed care and worldwide coverage.
What are out of network benefits?
100
Once the member is enrolled, this is when the plan begins.
What is the effective date?
200
Members of this plan can choose any provider they wish who accepts the plan's terms and conditions for payment.
What is a PFFS?
200
You can't eat this doughnut hole, but during this period you will be eating 100% of your costs.
What is the coverage gap?
200
This program determines which plan will pay first if two policies cover the same procedures.
What is Coordination of Benefits?
200
Fixed costs that are paid to the insurer to belong to the plan.
What is a premium?
200
This document will provide proof that a person had insurance during a certain amount of time.
What is Evidence of Coverage?
300
In this plan, if you go out of network, the client will pay 100% except in emergencies.
What is an HMO?
300
In 2009, if this reaches $2,700, the member will be in the coverage gap.
What is Total Drug Spend?
300
You may be qualified for this if you are at least 65, permanently disabled, or have End Stage Renal Disease.
What is Medicare?
300
Soon after enrollment, the member will receive this, which includes an ID card, provider information and other important documents.
What is a Benefit Package?
300
A general term for the amount of the member's responsibility in comparison to the insurer. Examples are deductibles and copayments.
What is cost sharing?
400
Members of this "hybrid" plan can enjoy HMO & PPO characteristics.
What is a POS?
400
This type of prescription has both brand & generic available.
What is a Multi-Source Drug?
400
This is what the participant must provide and remember in order to remain active in a plan.
What is patient or member responsability?
400
Applicants must go through this process in order to determine insurability.
What is Medical Underwriting?
400
Some medical and drug plans use this payment method on a percentage basis.
What is coinsurance?
500
Medicare is an example of this public plan which has no network.
What is a Fee For Service plan?
500
This is the actual amount the member pays for covered medicines to determine catastrophic coverage.
What is True Out Of Pocket?
500
Providers are considered this if they have no contract but accept the plan's terms and conditions of payment.
What is Deeming?
500
A provision in which the insured is allowed to stay in the plan regardless of any health conditions.
What is Guranteed Renewable?
500
A statement with detailed information that shows what is paid and what isn't paid.
What is an Explanation of Benefits?
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