Key Terms

The following definitions will help you understand key health care terms:

Key Health Care Terms
Co-payment or Co-pay

Set dollar amount you pay for doctor office visits and mail-order prescriptions. No other fees or deductibles apply.

Deductible

Dollar amount an individual or family must pay for covered care each calendar year before the medical plan pays benefits for most services—the deductible does not apply to doctor office visits, preventive or wellness care, prescriptions or routine lab work.

Co-insurance

Percentage of the cost for eligible medical and prescription expenses that you pay after you meet the deductible.

Co-insurance Out-of-Pocket Maximum

Annual dollar limit an individual or family pays in medical and prescription co-pays and co-insurance in a calendar year—plan pays 100% of eligible expenses when the out-of-pocket maximum is reached. This feature provides financial protection for you by limiting your out-of-pocket expenses in a given calendar year.

Allowable Charge

The maximum amount that a health benefit plan will pay for a given Covered Service or supply. Also called maximum benefit allowance, maximum allowance or reasonable charge.

Urgent Care

Services that are non-preventive or non-routine, and needed in order to prevent the serious deterioration of a member’s health following an unforeseen illness, injury or condition. Urgent care includes services rendered for conditions that could not be adequately managed without immediate care or treatment, but do not require the level of care provided in the emergency room.

Walk-In or Retail Clinics

Clinics that can be found in certain retail settings like in a CVS store, Walgreens or one of many other retailers. Care for minor acute conditions can be sought in this setting. These clinics offer high-quality care at no cost to you (no co-pay).