Benefits Verification (BV)

A process that confirms your benefits and eligibility or your insurance coverage for a prescription or medical service. 

Cost-Sharing Methods

• Co-insurance

  The percentage of a prescription or medical service that you pay after meeting your deductible.

• Co-pay

  A fixed amount you pay for a doctor’s visit, prescription, or other medical service.

• Out-of-pocket Maximum

  The most you’ll pay in medical expenses in a year before you’re fully covered.

Deductible

The amount you pay for healthcare services before your insurance starts paying.

Explanation of Benefits (EOB)

A statement from your insurance administrator that details what charges are eligible for benefits under your plan.

Formulary

The list of medicines that your health insurance plan will pay for or cover.

Health Insurance Benefits

The healthcare items or services covered under a health insurance plan. 

Health Savings Account (HSA)

An account that allows you to set aside pre-tax dollars to pay for yearly healthcare expenses. To be eligible to open an HSA, you must have a high-deductible health insurance plan. 

Insurance Plans

• Commercial Insurance

  Plans typically sold to consumers directly or to groups/employers.

• Government Insurance

  Insurance programs paid for and operated by the federal and state governments (examples: Medicaid, Medicare, and Veterans Affairs insurance).

Medicaid

A government insurance plan that offers healthcare coverage and drug benefits to low-income individuals.

Medicare

A federal government insurance plan that provides healthcare coverage options and drug benefits for persons over 65 years old, or disabled persons under the age of 65. 

Open Enrollment

An annual period during which people can enroll in a group-sponsored health insurance plan for the next year.

Patient Out-of-Pocket Costs

Your expenses for medical care that aren’t reimbursed by insurance. 

Pharmacy Benefit Manager (PBM)

A third-party administrator hired by the insurance plan to manage prescription drug coverage/programs for its insured population.

Premium

The amount you pay for health insurance every month. 

Prescription Benefits

Covered prescription drugs, usually self-administered, such as oral, injectable, or taken in other ways outside the physician’s office.

Prior Authorization (PA)

Your healthcare provider must provide additional information to your insurance company before they’ll cover a service or medication.