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 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 network doctor office visits, preventive or wellness care, prescriptions or routine lab work.

Co-insurance

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

Out-of-Pocket Maximum

The maximum annual dollar amount an individual or family pays for covered health care expenses, which includes co-pays, deductible and co-insurance. Once you reach this maximum, the plan covers 100% of the cost of any additional eligible expenses incurred for the rest of the calendar year. This feature provides financial protection for you by limiting your out-of-pocket expenses in a given calendar year. Any out-of-network expenses incurred in excess of the allowed amount are not included in this maximum number.

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 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).