The maximum amount used to determine the cost of covered health care services. May also be called allowable charge, eligible expense, payment allowance, or negotiated rate.
A bill for the difference between the amount the plan reimburses for covered services—the allowable amount—and what an out-of-network provider charges. You do not have to pay this amount if you see an in-network provider.
Drugs approved by the FDA that are under patent to the original manufacturer. They are only available under the original manufacturer’s brand name.
A provider’s request to your plan administrator asking to be paid for a service you’ve received.
The percentage of the cost you pay for covered health care services, after you meet your calendar-year deductible.
The amount you pay out of pocket for health care each calendar year before the plan begins to share in the cost of covered services. Both Meritain (Aetna network) medical plans have separate deductibles for in- and out-of-network care. What you pay for one doesn’t count toward the other.
Explanation of Benefits
After you get care, you’ll receive an Explanation of Benefits (EOB) from Meritain (Aetna network), the claims administrator. The EOB provides information about how your claim was paid, including how much you owe or will be reimbursed.
Flexible Spending Accounts (FSAs)
Special tax-advantaged spending accounts you can use to pay for eligible expenses. The Health Care FSA can be used to pay for eligible medical expenses. The Dependent Care FSA can be used to pay for eligible care expenses for your dependents. The limited-purpose FSA can be used to pay for eligible dental and vision care expenses if you have a Health Savings Account.
A list of drugs determined and maintained by CVS/caremark to use for its prescription drug program. The formulary is designed to assist physicians in prescribing drugs that are medically necessary and cost-effective.
Approved by the FDA as a therapeutic equivalent to the brand-name drug; has the same active ingredient as the brand-name version but at a lower cost.
Health Reimbursement Account (HRA)
An employer-funded group health plan that you can use to be reimbursed tax-free for qualified medical expenses up to a fixed dollar amount each year.
Health Savings Account (HSA)
Special savings account that comes with the CDHP. You save on taxes three ways with the HSA: no taxes on your contributions (including those from PayPal), no taxes when you use the money to pay for eligible medical expenses, and no taxes on interest earned on your account.
The facilities, providers, and suppliers your health plan has contracted with to provide covered health care services.
Prescribed to treat chronic health conditions—such as asthma, diabetes, high blood pressure, or high cholesterol—and are taken on an ongoing, regular basis to maintain health.
Prescription drugs listed under “non-preferred” generally have higher copays than preferred brand-name drugs.
Providers that are not in the Meritain (Aetna network) network or have not contracted with Meritain (Aetna network) and have not agreed to charge certain rates for certain services.
The most you’ll pay for covered health care services in a calendar year. Once you reach it, the plan pays 100% of the costs for covered services for the rest of the year.
Preferred provider organization (PPO)
A PPO is similar to a traditional fee-for-service plan, but you must use doctors in the PPO provider network or you will pay a higher coinsurance (percentage of charges) if you don’t. A PPO allows you to select most providers without a referral. Typically must meet an annual deductible before some benefits apply. You are responsible for a certain coinsurance amount, and the plan pays the balance, up to the allowable amount. You get maximum benefit coverage when you use the PPO network of physicians and hospitals.
Depending on your age and gender, your medical plan provides preventive services at no cost to you if you visit a participating provider and claims submitted are coded correctly. Follow-up testing for a diagnosed medical condition will generally not be covered as preventive.
These are drugs that are used to treat complex or chronic conditions that usually require close monitoring, such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancer, and other conditions that are difficult to treat with traditional therapies. Specialty drugs are obtained from the CVS/caremark pharmacies and may require prior authorization.