Brand Name Drug - a single source, FDA approved drug manufactured by one company for which there is no FDA approved substitute.

Coinsurance - the percentage of the covered expenses which must be paid by the member.

Copay or Copayment - a specified amount to a specific covered service for which the member is responsible (such as a $10 or $15 copayment per office visit).

Deductible - a specified amount of covered expenses for the covered services that must be paid by the member before the insurance carrier will assume any liability.

Dependent - the subscriber's legal spouse, or unmarried child (natural, legally adopted or placed for adoption, or stepchild), or child for whom the subscriber or subscriber's spouse is a court appointed legal guardian, who is within the limiting age for dependent status per the contract.

Durable Medical Equipment - equipment that can withstand repeated use and is primarily and customarily used to serve a medical purpose. It is generally not useful to a person without an illness or injury and is appropriate for use in the home. Durable medical equipment includes hospital beds, crutches, canes, wheelchairs, walkers, peripheral circulatory aids, cervical collars, traction equipment, physiotherapy equipment, oxygen equipment, ostemy supplies, etc.

Effective Date of Coverage - the date of coverage begins for a member, usually 12:01 a.m. on the date reflected on the records of the insurance carrier.

Emergency Services - any health care services provided to a member after the sudden onset of a medical condition. The condition manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • placing the health of the member or the health of a member's unborn child serious jeopardy;
  • serious impairment of bodily functions;
  • serious dysfunction of any bodily organ or part.

Employee - an individual of the group who meets the eligibility requirements for enrollment as set forth by the insurance carrier.

Formulary - a defined list of brand name and generic medications that have been selected for their effectiveness and value.

Generic Drug - a pharmacological agent approved by the FDA as a bioequivalent substitute and manufactured by a number of different companies as a result of the expiration of the original patent.

Health Maintenance Organization (HMO) - a type of managed care plan in which the member is required to select a primary care physician to provide and coordinate all covered medical care, including referrals for specialist services.

Inpatient Care - treatment received as a bed patient in a hospital, a skilled nursing facility a rehabilitation hospital, or a substance abuse treatment facility.

Member - a subscriber or dependent who meets the eligibility requirements for enrollment as set forth by the insurance carrier.

Office Visits - covered services provided in the physician's office and performed by or under the direction of the primary care physician or a specialist.

Outpatient Care - medical, nursing, counseling or therapeutic treatment provided to a member who does not require an overnight stay in a hospital or other inpatient facility.

Primary Care Physician - a participation provider selected by an HMO member who is responsible for providing all primary care covered services and for authorizing and coordinating all covered medical care, including referrals for specialists services.

Referred Specialist - an HMO provider who provides covered specialist services upon referral from a primary care physician.

Pre-approval - the approval that an HMO primary care physician or referred specialist must obtain from the insurance carrier to confirm coverage for certain covered services.

Pre-Certification - prior assessment by the insurance carrier that proposed services (e.g., hospitalization) are medially appropriate and necessary for a member and are covered by the member's insurance plan.

Preferred Provider Organization (PPO) - a type of managed care plan that offers the freedom to choose a physician like a traditional health care plan and provides the physician visits and preventive benefits normally associated with an HMO. In a PPO a member is not required to select a primary care physician to coordinate care and is not required to obtain referrals to see specialists.

Referral - written documentation from an HMO member's primary care physician that authorizes covered services to be rendered by a participating provider specifically named on the referral.

Subscriber - the person who is eligible and is enrolled for coverage.

These are brief definitions only; please refer to the your contract and benefit booklet for details regarding provisions, limitations, and exclusions.

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