Common Insurance Terms & Phrases

Benefit maximum - A benefit maximum is a limit on a covered service. A service may be limited by dollar amount, duration or number of visits. To review your benefit maximums please refer to your member policy document.

Co-insurance - Co-insurance is a specified percentage. Depending on your plan you may be responsible for a certain percentage, while your health insurance plan pays the remaining percentage.

Copay - Regardless of the cost of the service, a copayment is a specified dollar amount that an individual pays for health care services, in addition to what the insurance covers.

Deductible - The amount an individual must pay for health care expenses before insurance covers the costs.

Formulary - A drug formulary is a tool used by many insurance companies in an effort to standardize care, improve the quality of care and reduce premium costs.

Out-of-network/Non-plan/Non-participating providers - Refers to physicians, hospitals or other health care providers who are not contracted with Prevea360 Health Plan, which could result in a greater cost for services or fewer savings for you.

Out-of-pocket maximum - A predetermined limited amount of money that an individual must pay out of their own pocket.

Preventive care - Preventive care refers to certain services such as physical exams, preventive mammograms, Well Baby and Well Child Checkups and immunizations (excluding immunizations required for travel) that are recognized by the federal government to prevent illness and promote ongoing health and wellness.

Prior authorization - A prior authorization is sometimes required for certain services to ensure you are receiving the most medically appropriate and cost-effective care or if you are seeking care from an out-of-network or non-participating provider.