PPO(Preferred Provider Organization) Insurance
A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan¡¯s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
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In Network(Preferred Provider)?vs Out of Network(Non-Preferred)
Most health plans have a list of doctors, hospitals, and other providers that have agreed to participate in the plan¡¯s network. Providers in the network have a contract with your plan to care for its members at a certain cost. You pay less for medical services when you use one of the providers on this list.
If you see a doctor or use a hospital that does not participate with your health plan, you are going out-of-network. You usually have to pay more for out-of-network care. Some plans won¡¯t cover any amount of out-of-network care. Some cover a percentage of care
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Deductible
The amount you owe for covered health care services before your health insurance or plan begins to pay. For example, if your deductible is $1,000, your plan won¡¯t pay anything until you¡¯ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
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Co-Insurance
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan¡¯s allowed amount for an office visit is $100 and you¡¯ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
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Out of pocket Maxinum
The most you pay during a policy period (usually one year) before your health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.
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Co-payment
A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
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Drug Generic and Brand Tire 1, 2, 3
Drugs on a formulary are typically grouped into tiers. The tier that your medication is in determines your portion of the drug cost. A typical drug benefit includes three or four tiers:
Tier 1?usually includes generic medications.
Tier 2?usually includes preferred brand name medications.
Tier 3?usually includes non-preferred brand name medications.
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