We make health insurance easier to understand by defining the words we use to describe your medical and prescription drug benefits. If you’re wondering what something means, check this list of insurance terms with some easy to understand definitions.
The most we will pay a provider for a covered health care service.
This is a general category for three complex disorders of brain development. Autism spectrum disorders include:
The 12 months during which your health insurance benefits are calculated. Your benefit year and the calendar year don’t necessarily coincide. Your health insurance benefits may update or renew at the beginning of the benefit year.
These are services related to muscles, bones and the nervous system that might help you address back pain, neck pain, joint pain or headaches.
A request we receive from you or your doctor to pay for medical services you’ve received.
A clinical trial is a test of a new drug, device or medical treatment on people. Ask your health care provider to request prior authorization from us before you participate in a clinical trial. This will help you determine whether services related to a clinical trial will be covered.
A system used to eliminate duplication of benefits when you are covered under more than one health insurance plan. Benefits under the two plans usually are limited to no more than 100 percent of the claim.
For example, many plans have copayments ($20 for example) for certain services such office visits.
This is the amount you owe for health care services before your health insurance begins to pay. Not all plans have deductibles.
For example, a member with a high-deductible health plan that has a deductible of $2,000 is required to pay $2,000 for medical care before the health plan can begin paying for claims under the terms of the insurance coverage.
A spouse or child who is covered under your health insurance plan.
A drug formulary is a list of drugs covered by your health plan.
Drugs in your formulary are organized by how much you will pay when you fill a prescription. The different categories of prices are called drug tiers. The lower the tier, the less you will pay for drugs in that tier. Tier 1 drugs are most often generic medications. Tier 2 drugs are usually preferred name-brand drugs and non-preferred generic medications. Tier 3 drugs are non-preferred name-brand drugs. Some plans have additional tiers for specialty medications or immunizations.
Equipment and supplies ordered by a health care provider for your everyday or extended medical use. Coverage might include oxygen equipment, wheelchairs, crutches or diabetic blood-testing strips.
The date your health insurance coverage begins.
An illness or injury so serious that a reasonable person would seek care right away to avoid severe harm. These are situations where a lack of immediate medical attention will likely result in:
Health care services that we do not pay for or cover.
See "Personal Health Statement."
A generic drug is a non-name brand version of a prescription drug. A generic drug usually costs less than its name-brand equivalent.
A complaint that you make to us.
Health care services that help you keep, learn or improve skills related to daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. Services might include physical and occupational therapy, speech-language pathology, and other services for people with disabilities.
These are services you receive from a health provider at your home, or under a written home care plan submitted by your attending physician.
These are specific services you receive when a physician says you have six months or less to live. The care is available on an intermittent basis with on-call services available on a 24-hour basis. It includes services provided to you to ease pain and make you as comfortable as possible.
When you face a hospital stay, your hospital will tell us how many days it expects you to stay. We then will grant, or pre-certify, your hospital stay for a certain number of those days. We might pre-certify you to stay fewer days than the hospital expects you to stay. Your hospital then must prove that the additional days are medically necessary for you to receive coverage for those days.
If your doctor wants to prescribe a drug for you that we normally don’t cover, you can request a medical exception. A medical exception sometimes is called a formulary exception or prior authorization. You or your provider may request the medical exception in writing or by verbal request.
A doctor, health professional or health care facility that has a contract with your health insurance plan and whose services would be covered under your policy.
This is a prescription drug that has not yet been approved by the Food and Drug Administration (FDA). We usually do not cover new drugs for six months after FDA approval.
The most you will pay in one year before we pay the entire cost of your health care services. This limit does not include your premium or services we don’t cover.
Many insurance companies call this an Explanation of Benefits. This is a document Security Health Plan sends you after we receive a claim for your health care services. It explains the services you had, what they cost, payments Security Health Plan made to the provider on your behalf and additional payments you might owe the provider.
This is the amount you or your employer pays each month for your insurance coverage.
A request made by a physician or other health care provider who is authorized to prescribe medication.
Services to help you avoid becoming sick. Mammograms, flu shots, Pap tests and pelvic exams are examples of preventive services.
A physician, nurse practitioner or physician’s assistant in adolescent medicine, family practice, internal medicine, general practice or pediatrics who you see to coordinate your health care.
Our decision that a specific health care service for you is medically necessary and will be covered.
You can receive some drugs only in limited amounts or only so many times in given time periods. These are drugs with quantity limits.
A document that describes how much you will pay for specific covered services, and describes specific benefits and benefit limitations under the terms of your Policy or Certificate.
Prescription medications that treat long-term diseases such as rheumatoid arthritis, psoriasis, multiple sclerosis and cancer. They are usually more complex in design and how they are taken than other drugs. They are available in injectable or oral forms. Specialty drugs require personalized coordination between your provider and the dispensing pharmacy. Specialty pharmacies are experienced in handling these medications and they offer additional support to members.
In some cases, you might be required to try certain drugs to treat your medical condition before we will approve coverage for a different drug for that condition. This process is step therapy.
Drugs that can help you quit smoking or chewing tobacco.
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.