Allowed amount – 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.
Claim – A provider’s request to your plan administrator asking to be paid for a service you’ve received.
Coinsurance – The percentage of the cost you pay for covered health care services, after you meet your calendar-year deductible.
Copay – This is a specific dollar amount you pay at the time of service, for example for a doctor’s visit or when you pick up a prescription.
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. PPO Plans and High Deductible Health Plans operate slightly differently in that full deductible must be met before the plan begins to share in the cost, whereas certain copays are applicable before deductible is met.
Explanation of Benefits (EOB) – After you receive care from a provider, you’ll receive an EOB from your health care provider. The EOB provides information about how your claim was paid, including how much you owe or will be reimbursed depending on where the service is rendered.
Generic drugs – Drugs that are 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 Savings Account (HSA) – Healthcare savings account that accompanies enrollment in the Cigna HDHP 3000 and allows you to put away pre-tax dollars to be used towards eligible medical expenses. You save on taxes in three ways: no taxes on your HSA contributions, no taxes when you use the money to pay for eligible medical expenses, and no taxes on interest earned on your account through WEX.
In-network – The facilities, providers, and suppliers Cigna has contracted with to provide covered health care services.
Maintenance medications – Drugs that are 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.
Non-Preferred Brand Drugs – Drugs that are listed under “non-preferred brand drugs” generally have higher copays than preferred brand-name drugs.
Out-of-network – Providers that are not in the Cigna network or have not contracted with Cigna and have not agreed to charge what Cigna has deemed fair value. Services that occur out-of-network are subject to balance billing and leave members facing larger than expected owed amounts.
Out-of-pocket maximum – The most you’ll pay for covered health care services in a calendar year. Once you reach the out-of-pocket maximum, the plan pays 100% of the costs for covered services for the rest of the year. Out-of-network plans are still subject to balance billing even after out-of-pocket maximum has been met.
Preferred Brand Name Drugs – Drugs approved by the FDA that are under patent to the original manufacturer. They are only available under the original manufacturer’s brand name.
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. You 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.
Preventive care – Depending on your age and gender, your medical plan provides preventive services (such as screenings, immunizations, and exams) 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.
Specialty medications – 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 pharmacies in our medical plan networks and may require prior authorization.