The amount a member pays each calendar year for covered services before the plan’s coinsurance (cost sharing) begins. The deductible resets every January 1st.
The member’s flat dollar payment or “copay” at point of service.
The cost sharing element of the plan expressed as a percentage of charges. Coinsurance payments are based on negotiated rates.
Out of Pocket Maximum (OOP)
The maximum amount a member will pay for covered services in a calendar year. Once met, the plan pays 100% for all covered services when in-network.
Preferred Drug List (PDL)
A list (sometimes also referred to as a formulary) that outlines how a particular medication is covered under the different prescription tiers. PDLs change throughout the year, and members are notified by mail when/if a change will affect them.
The hospital, physician, laboratory, or other medical provider who has contracted with the insurance carrier and has agreed to a negotiated rate for services.