terms

• Premium


  The monthly or yearly payment you make to your insurance company to maintain coverage
• Deductible


  The amount of money you must pay out-of-pocket for covered medical services before your insurance starts paying
• Copay


  A fixed amount you pay for a covered medical service, typically a doctor's visit or prescription medication
• Coinsurance


  A percentage of the cost of a covered medical service that you are responsible for paying after you have met your deductible
• Out-of-pocket maximum


  The most you will have to pay for covered services in a plan year, after your deductible and coinsurance are met
• Network


  The group of doctors, hospitals, and other healthcare providers that your insurance company contracts with to provide services at negotiated rates
• In-network


  Refers to a doctor, hospital, or other healthcare provider that participates in your insurance company's network
• Out-of-network


  Refers to a doctor, hospital, or other healthcare provider that does not participate in your insurance company's network. You will typically pay more for out-of-network services
• Pre-existing condition


  A medical condition that you had before you enrolled in your health insurance plan. Some plans may have limitations on coverage for pre-existing conditions
• Affordable Care Act (ACA)

  A law passed in 2010 that reformed the healthcare system in the United States. Among other things, the ACA requires most Americans to have health insurance and prohibits insurers from denying coverage or charging more based on pre-existing conditions
• High-deductible health plan (HDHP)


  A health insurance plan with a lower monthly premium but a higher deductible. HDHPs are often paired with a health savings account (HSA), which allows you to save money tax-free to pay for qualified medical expenses
• Health savings account (HSA)


  A savings account that allows you to set aside money tax-free to pay for qualified medical expenses. HSAs can only be used with HDHPs
• Flexible spending account (FSA)


  An account that allows you to set aside pre-tax dollars from your paycheck to pay for qualified medical and dependent care expenses. Unlike HSAs, FSAs do not roll over unused funds at the end of the year
• Prior authorization


  A process that requires you to get approval from your insurance company before you receive certain medical services
• Claim


  A request for reimbursement from your insurance company for covered medical services
• Explanation of benefits (EOB)

  A document from your insurance company that explains how much they will pay for a covered medical service and how much you are responsible for
• Medicare


  A federal health insurance program for people age 65 and older, as well as younger people with certain disabilities
• Medicaid


  A federal and state program that provides health insurance to low-income adults, children, pregnant women, seniors, and people with disabilities
• Open enrollment period


  The time of year when you can choose or change your health insurance plan on the health insurance marketplace
• Health insurance marketplace


  An online marketplace created by the ACA where you can shop for and compare health insurance plans
• Prescription drug benefit


  The part of a health insurance plan that covers the cost of prescription medications
• Formulary


  A list of drugs that are covered by a health insurance plan
• Tiered formulary


  A formulary that has different cost-sharing requirements for different categories of drugs. For example, a tiered formulary may have a lower copay for generic drugs than for brand-name drugs
• Prior authorization


  A process that requires a doctor to get approval from an insurance company before a patient can receive a certain medication
• Quantity limit


  The maximum amount of a medication that an insurance company will cover at one time
• Refill


  The act of getting a new supply of a medication after the original prescription has run out
• Mail-order pharmacy


  A pharmacy that dispenses medications by mail. Mail-order pharmacies often offer lower prices than traditional retail pharmacies
• Maintenance medication


  A medication that is taken on a regular basis to manage a chronic condition
• Specialty drug


  A medication that is used to treat a complex condition and is typically expensive and/or requires special handling
• Copay


  A fixed dollar amount that you pay for a covered medication
• Coinsurance


  A percentage of the cost of a covered medication that you are responsible for paying after you have met your deductible
• Deductible


  The amount of money you must pay out-of-pocket for covered medications before your insurance starts paying
• Out-of-pocket maximum


  The most you will have to pay for covered medications in a plan year, after your deductible and coinsurance are met
• Non-formulary drug


  A medication that is not covered by a health insurance plan. You will typically have to pay the full cost of a non-formulary drug
• Pharmacy benefit manager (PBM)


  A company that negotiates drug prices with pharmaceutical companies on behalf of health insurance companies. PBMs also develop and maintain formularies
• Medicare Part D


  The prescription drug benefit program for Medicare beneficiaries
• Medicaid


  A federal and state program that provides health insurance to low-income adults, children, pregnant women, seniors, and people with disabilities, including coverage for prescription drugs
• Accumulator


  A system used by some insurance plans to track how much you have spent on your deductible for covered medications. Once you have reached the accumulator threshold, your insurance plan will start to cover the cost of your medications
• Gap coverage


  A type of insurance that helps to cover the gap in coverage between the end of your employer-sponsored health insurance plan and the start of Medicare Part D
• GoodRx


  A website and app that helps you find discounts on prescription medications