CHIP – Children’s Health Insurance Program providing low cost or free insurance coverage to qualifying children and teens up to the age of 19. This program is for families whose income does not qualify for Medicaid insurance coverage but who cannot afford private insurance.
Co-insurance – Your share of the costs of a covered healthcare service, calculated as a percent (for example, 20 percent), after you have met your deductible. For example, if the health-insurance plans allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20 percent would be $20. The health insurance pays the balance of the allowed amount.
Donut hole (or coverage gap) – Most Medicare prescription drug plans have a coverage gap, also called the “donut hole.” This refers to a temporary limit on prescription drug coverage, where the policy holder needs to pay a higher percentage of his or her medications after reaching this limit. Coverage then resumes after the individual reaches a higher level of out-of-pocket expenses, at which time the individual would automatically receive “catastrophic coverage.” For the remainder of the year, only a small co-insurance amount or co-payment for covered drugs would be required.
- Tier 1: The generic version of a brand-name medication; they have the exact same active ingredients as their brand-name counterparts.
- Tier 2: Brand-name medications that are on a list of preferred drugs.
- Tier 3: Preferred specialty brand-name drugs.
- Tier 4: Medications classified as those that require special dosing or administration; these are typically prescribed by a specialist and are more expensive than most medications.
Outpatient Services – Medical procedures or tests that can be done in a medical center without an admission to the facility. Laboratory tests, radiology, or a visit to the Emergency Department for diagnostic services, are all examples of outpatient services.
Prior Authorization – A requirement that your physician must obtain approval from your health plan to prescribe a specific medication for you. Without this prior approval, your health plan may not provide coverage or pay for your medication.