Prescription Terms
shared percentage of bill with insurance company for rx
Coinsurance
shared percentage of bill with insurance company
Coinsurance
provider recommends member to another provider
Referral
Mouth, Eyes, Ears
Dental, vision, hearing
Are Prior Auths Needed for medical services with PPO Plans?
NO
set amount for rx
Copayment
most paid oop before plan pays all of covered services
Maximum Out of Pocket
Who can be a PCP?
INN Provider
OTC products you may shop online
OTC Catalog benefit
Are Prior Auths Needed for some medical services with HMO Plans?
Yes
amount paid before plan kicks in
Deductible
fill when transitioning between plans
Transitional Fill
Periods where you may enroll in plan.
Enrollment Period
Free one way trips up to limit listed in plan
Transportation
Hmo's typically require referrals, PPO's do not.
Difference between HMO vs PPO
a location where you either pay regular price for rx or discounted price
Standard vs Preferred Pharmacy
set amount for service
Copayment
Who qualifies for DSNP plans
Individuals who have both Medicaid and Medicare parts a and B
Free membership to any silver sneakers participating gym
Fitness benefits
Can I still see INN specialist without a referral on some Aetna HMO plans?
Yes, depending on the location and plan
request by provider prior to approval for rx
Prior Authorization
Who qualifies for DSNP plans?
Individuals who have both Medicaid and Medicare parts a and B
exception request by provider for denied rx.
Formulary Exception
Reduction in the amount paid each month to SSI
Part B Premium Reduction
Are OON providers obligated to treat plan members in PPO plan networks?
No, except in emergency, only contracted providers are obligated to treat plan members.