Below are definitions of some terms that are used in this guide:
Co-insurance: when you pay a percentage of medical charges instead of a fixed amount.
Co-pay: when you pay a fixed dollar amount for a medical service.
Deductible: the amount you pay each year toward certain covered expenses before your plan starts paying benefits.
Formulary: a preferred list of commonly prescribed medications that are selected based on their clinical effectiveness and opportunity to help contain costs within a prescription drug program. Non-formulary drugs are any drugs not found on this list.
Health Maintenance Organization (HMO): a type of health plan that consists of a network of doctors, hospitals, and other health care providers. This type of plan will not pay for an out-of-network provider except in emergency situations. Unlike traditional HMOs, with Duke Select, Duke Basic, and Blue Care, you do not need a referral from your Primary Care Physician (PCP) to see a network specialist.
Maintenance Medications: medications that a provider has prescribed for regular (e.g., daily) use. These include (but are not limited to) heart/ulcer/blood pressure medication, hormone therapy, and birth control pills.
Network: a group of doctors, hospitals, and other providers that have contracted with an HMO or PPO and have agreed to accept a lower percentage of usual, customary, and reasonable (UCR) rates.
Out-of-Pocket Expense: the amount you pay toward a medical, dental or vision service that isn’t reimbursed by your insurance plan.
Preferred Provider Organization (PPO): a type of health plan that consists of a network of doctors, hospitals, and other health care providers. You may visit doctors outside of this network for most services. If you use an innetwork provider, you will be responsible for a lower portion of the bill than you would if you used an out-of-network provider.
Primary Care Physician (PCP): a health care provider (such as a nurse practitioner, physician, or physician assistant) who belongs to a network and who provides primary medical care in internal medicine, pediatrics, family practice, and/or general practice.
Specialty Medications: medications used to help manage complex and chronic health conditions such as anemia, cancer, rheumatoid arthritis, multiple sclerosis, and cystic fibrosis as well as other conditions. These medications usually have specialized ingredients and often need to be stored and/or handled in distinct ways. Beginning January 1, 2017, these are not covered if purchased through a retail pharmacy unless it is a “STAT” medication. See the HR website for a link to ESI listing of Specialty Medications.
Usual and Customary: This refers to the standard or most common charge for a specific medical, dental or vision service when rendered in a particular geographic area.