Medical Terms
The fixed dollar amount the member pays for a service.
What is copay?
This plan covers the cost of an insured individual’s medical and surgical expenses.
What is health/medical insurance?
This type of medical funding plan where the employer pays a defined monthly premium to the insurance carrier.
What is fully-insured?
A copy of a brand-name drug that have exactly the same dosage, intended use, effects, side effects, route of administration, risks, safety and strength as the original, brand-name drug.
What are generic drugs?
"Just keep swimming!"
What is Finding Nemo?
The most a member pays during a benefit year.
What is maximum out of pocket?
A type of medical plan where the member must choose a PCP and there is no out-of-network coverage.
What is an HMO?
A type of medical plan where the employer sets aside a certain amount of money each year for the member to use for medical expenses (typically deductible and coinsurance).
What is an HRA?
A medicine that is discovered, developed and marketed by a pharmaceutical company.
What is a brand name drug?
"Life is like a box of chocolates, you never know what you're gonna get."
What is Forrest Gump?
A fixed dollar amount during the benefit year that a member pays before the insurance company starts to pay for covered medical services.
What is deductible?
A type of medical plan that provides the most flexibility and offers both in-network and out-of-network coverage.
What is a PPO?
A type of plan with fixed monthly payments and a potential refund if claims are lower than expected.
What is level-funded?
A high-cost prescription medications used to treat complex, chronic conditions.
What are specialty drugs?
"Show me the money!"
On a two-person or family contract, each family member must meet their own individual deductible.
What is an embedded deductible?
A type of medical plan that is a hybrid of an HMO and a PPO plan. It requires a PCP, but offers out-of-network coverage.
What is a POS?
What is self-funded?
Prescriptions are sent directly to the member’s home by mail.
What are mail order prescriptions?
On a two person or family contract, the overall family deductible must be met before the plan begins to pay.
What is an aggregate deductible?
A type of medical plan that features High Deductibles, Lower Premiums and can be paired with a savings account.
What is an HSA or HDHP plan?
The entity that processes claims and maintains eligibility for level-funded or self-funded plan.
*Hint, three letter acronym.
What is a TPA?
A type of plan limitation where the insurance company needs to review why a drug has been prescribed before agreeing to pay for it.
What is prior-authorization?
"Happiness can be found, even in the darkest of times, if one only remembers to turn on the light."
What is Harry Potter and the Prisoner of Azkaban?