University Human Resource Services
Medical Care Plans Definitions
copay. The member’s share of a covered expense. For example, if a plan pays 90 percent, the member’s copay is 10 percent. Some plans have a fixed dollar copay on some services, such as $20 for office visits.
deductible. The dollar amount of covered services an individual must pay each plan year, before the plan begins reimbursement.
formulary. A list of preferred brand drugs that usually have a lower copay based on a clinical efficacy and cost. Sometimes called select drugs.
Health Savings Account (HSA). An IRS-qualified account that provides substantial tax savings features and must be combined with an IRS-qualified High Deductible Health Plan. The Medical Savings feature of the IU HDHP PPO & Medical Savings Plan is an HSA. Contributions to and distributions from an HSA are regulated by the IRS.
High Deductible Health Plan (HDHP). A health plan that has a deductible and other features defined by IRS regulations. The IRS requires participation in an HDHP in order to make contributions to an HSA.
in-network benefits. Benefits for covered services rendered by a network of contracted physicians and hospitals. Users of in-network providers receive greater benefits for services.
member. Any person covered under a plan, including employee, spouse or child. Sometimes also referred to as enrollee or participant.
network. A group of physicians and hospitals who have agreed to provide medical services under a contracted arrangement. Members receive greater benefits for using network providers.
out-of-network benefits. Benefits for covered services rendered by noncontracted physicians and hospitals. Users of out-of-network providers receive lower or no benefits for service.
primary care physician (PCP). A network physician selected by the member to provide routine care and arrange for specialty care.
routine eye exam. An annual exam performed to detect undiagnosed eye health problems and to measure visual acuity (refraction). An annual eye exam for those with diabetes is covered as routine.
maximum allowable amount. Benefits for covered services are based on the Maximum Allowable Amount (sometimes called Usual & Reasonable), which is the maximum amount the Plan will pay for a given service. Network providers have agreed to accept the Maximum Allowable Amount as payment in full. When you use a Non-Network Provider you are responsible for any balance due between the Non-Network Provider’s charge and the Maximum Allowable Amount in addition to any coinsurance, copayments, deductibles, and non-covered charges.
wellness services. Preventive services such as child immunizations, screening tests (e.g., mammograms), and annual physicals.
