Practical Resources

Glossary

Short, plain-language definitions. For more detail, open the related Learning Center module or download the Quick Guide PDF.

Allowed amount

The amount a plan recognizes for a covered service. It may be lower than the amount a provider bills.

Claim

A request for payment sent to the health plan for services you received.

Coinsurance

A percentage of the allowed cost of a covered service that the member may pay. Learn more about Coinsurance

Copay

A fixed amount that may apply to certain covered services. Learn more about Copay

Cost-sharing

The share of costs for covered services that the member pays, such as deductibles, copays, and coinsurance. Learn more about Cost-sharing

Deductible

An amount you may need to pay toward certain covered services before the plan begins paying its share. Learn more about Deductible

EOB (Explanation of Benefits)

A statement explaining how a claim was processed. An EOB is not a bill. Learn more about EOB (Explanation of Benefits)

Formulary

A plan’s list of covered prescription drugs.

HMO / PPO / EPO

Common plan types that differ in network flexibility, referrals, and out-of-network rules. Learn more about HMO / PPO / EPO

In-network / Out-of-network

Whether a provider has an agreement with your specific plan. Learn more about In-network / Out-of-network

Out-of-pocket maximum

An annual limit on applicable cost-sharing for covered in-network services. Learn more about Out-of-pocket maximum

Premium

The amount paid to maintain health coverage, often monthly. Learn more about Premium

Prior authorization

A process in which a plan may require approval before certain services or medications are covered. Learn more about Prior authorization

Referral

Direction from a primary care provider to see a specialist, often required by HMOs.