Common Terms & Resources

PPO

You have the freedom to see any physician, located in any area; however, to receive the maximum benefits under the plan, physicians should be chosen from the network of participating providers. You may also use a doctor that is not in-network and receive reduced, out-of-network benefits. Primary care physicians do not need to be designated, and referrals are not needed to visit specialists.

Preventive Services

Preventive services are covered at 100% in-network and copays & deductibles do not apply.

There are 3 sets of free preventive services. Select the links below to see a list of covered services for each group:

• For all adults
• For women
• For children

Online Healthcare

A virtual visit lets you see and talk to a doctor from your mobile device or computer. When you use one of the provider groups in our virtual visit network, you have benefit coverage for certain non-emergency medical conditions. Costs must be paid by you at the time of the virtual visit and will apply toward your deductible and out-of-pocket maximum.

Find a Doctor

You pay less out of pocket if you receive care from an In-Network provider. In-Network providers can be found on your provider’s website under “Find a Doctor”. Log in to your account and choose the network based on the plan type you are choosing.

Deductible

The amount of money you are responsible for paying each year before the plan begins to pay for covered services, with the exception of preventive care services, which are covered at 100% In-Network.

Coinsurance

Your share of the expense of covered services after your deductible has been paid when the company plan is paying a percentage. The coinsurance rate is usually a percentage.

Out-of-Pocket Maximum

The most you pay per Plan Year for health care expenses and applies to deductibles, flat-dollar copays and coinsurance for all covered services – including cost-sharing amounts for prescription drugs. Once this limit is met, the plan will cover all in-network services at 100% until the end of the plan year.

Common Pharmacy Tiers

Generic | Lowest copay: Most drugs in this category are generic drugs. Members pay the lowest copay for generics, making these drugs the most cost-effective option for treatment.

Preferred Brand | Higher copay: This category includes preferred, brand name drugs that don't yet have a generic equivalent. These drugs are more expensive than generics, and a higher copay.

Non-Preferred Brand | Highest Brand copay: In this category are nonpreferred brand name drugs for which there is either a generic alternative or a more cost-effective preferred brand. These drugs have the highest copay. Make sure to check for mail order discounts that may be available.

Preferred Specialty | Lowest specialty drug copay: Preferred specialty drugs are generally more effective and less expensive than non-preferred specialty drugs.

Non-Preferred Specialty | Highest specialty drug copay: These drugs have the highest copay for specialty drugs, usually because there may be a more cost-effective generic or preferred brand available.

Finding a Drug List

Typically, a full listing of covered drugs is found on your provider’s website. A drug list, also called a formulary, is a list of generic and brand-name drugs covered by a health plan. Although a drug may be on the drug list, it might not be covered under every plan. Review the plan materials for details on specific benefits. You can use drug lists to see if a medication is covered by your health insurance plan. You can also find out if the medication is available as a generic, needs prior authorization, has quantity limits and more.