Insurance Terms
The amount of covered health care expenses you must pay yourself each year before your plan will begin to pay
What is deductible?
HMO
What is Health Maintenance Organization?
POS, HMO, PPO, EPO
What are different types of medical plans?
The JHMB program that requires members to obtain maintenance medications either by mail or from Costco, Rite-Aid, and CVS
What is Rx90?
This term is used to describe the maximum amount of money a member is responsible for paying during a calendar year before plan covers 100% of medical costs
What is out of pocket maximum?
PPO
What is Preferred Provider Organization?
United Healthcare HMO and Delta PPO are this type of plan for JHMB, covering 100% of x-rays and cleanings
What are dental plans?
A term for medications that treat non–life-threatening and non-painful conditions such as baldness, wrinkles, erectile dysfunction, acne, or sleepiness
What is a lifestyle drug?
This document is sent by an insurer to a patient explaining what was covered for a medical service, and if they owe copayments or coinsurance
What is Explanation of Benefits?
COBRA
What is Consolidated Omnibus Budget Reconciliation Act?
These two types of documentation are required to obtain certain medical services, behavioral health services, or medications
What are letters of medical necessity, prior authorizations, or precertification?
These drugs approved for medical use in 2013-2014 treat hepatitis C and are on the World Health Organization's List of Essential Medicines
What are Sovaldi and Harvoni?
The process that a health insurer uses to weigh potential risks in its pool of insured people against potential costs of providing coverage
What is underwriting?
EGWP
What is Employer Group Waiver Plan?
Anthem, HM Insurance Group, Sun Life, Tokio Marine (HCC), Voya Financial, Zurich
What are stop loss carriers?
The Pharmacy Committee refers to medications that can be obtained under both the medical and pharmacy benefit in this way
What is dual-channel drug?
With the latest renewal, there is one of these exclusions of stop-loss coverage for an individual in the PPO; cats like them too
What is a laser?
The PATH in WellPATH
What is Personal Accountability To Health?
aspirin, escalator, heroin, kerosene, laundromat, trampoline and zipper
What are names that have lost their trademark protection and are now generic names for products in their category?
What are generic names for products that were once trademarks?
A 1% increase in this metric can lead to 2-3% plan cost savings (estimated $450k to $700k annually)
What is generic dispensing rate/ratio?