What is medical insurance? Medical insurance covers the cost of most health care visits, medications, tests, surgeries and hospital stays so that you do not have to pay full price, or out of pocket.
Common Medical Insurance Terms
Deductible: This is the out-of-pocket amount you have to pay once during a coverage period (usually one year) upfront before your insurance will cover costs. Example: You have a $200 deductible. You get blood tests that cost $75. You are billed $75. Once you meet the $200 threshold, your insurance covers the costs.
Co-pay: This is the amount you have to pay each time during a coverage period. This normally applies to prescriptions, office visits, or supplies and payment is requested at the time of service. You are responsible for paying the copay amount every time you go to an appointment or pick up a prescription. Example: You have a $25 copay to see an off-campus healthcare provider. You pay $25 every time you are seen.
Medications and their copayments are grouped into categories of cost, called tiers. Tier 1 medications are usually the least expensive. Copay amounts under the Smith Student Health Insurance Plan are $15, $30, $50 and $100. If the actual cost of medication is less than your copay amount, you only pay the cost of the medication. You will never be asked to pay more than the copay amount.
Prior Approval/Prior Authorization: This means your insurance company only covers a medication or service if it meets certain criteria. Example: The pharmacist tells you a medication requires Prior Authorization and contacts the office. If the office provides information to meet requested criteria, you will be asked to pay the regular copay amount. If not, either you can pay full price or ask the office to prescribe an alternative.
Formulary: This is the list of services, medications and supplies your insurance covers.
In-Network: These are the providers, suppliers and facilities your insurance covers.
Out-of-Network: These are providers, suppliers, and facilities your insurance does not cover, or only covers partially.
Emergency Room: The 24-hour department of a hospital that provides care for life-threatening emergencies. Same as Emergency Department or ED.
Urgent Care: The clinic or hospital department that provides care without an appointment when you are sick or injured. Often called a Walk-In Clinic.
Generic Medication: The least expensive form of a medication, often referred to as the active ingredient. Example: Ibuprofen (same drug as name brand Motrin).
Brand Name Medication: The manufacturer’s trademark name of medication. Example: Motrin (same drug as Ibuprofen)
Referral: This is the formal process through which your health care provider asks your insurance company to cover your visits with a specialist, and asks that specialist to participate in your care.