2025 Benefits Guide- updated 10-20 - Flipbook - Page 5
Key Terms to Know
Deductible: The amount you pay for covered health care services before your insurance plan starts
to pay.
Collective deductible: All family members contribute towards the family deductible. An individual
cannot have claims covered under the plan coinsurance until the total family deductible has been
satisfied.
Stacked deductible: Family members meet only their individual deductible and then
their claims will be covered under the plan coinsurance; if the family deductible has been met prior
to their individual deductible being met, their claims will be paid at the plan coinsurance.
Co-payment: Fixed dollar amounts (for example, $15) you pay for covered health care,
typically at the time of service.
Coinsurance: Percentage of costs of a covered health care service that you pay (20%, for
example) after you’ve paid your deductible.
Out-of-pocket maximum: The most you would pay in a year*/point at which the plan pays 100%.
In-network providers: Health care providers contracted with the insurer to provide services at the
set, discounted fee schedule, not allowed to “balance bill”.
Reasonable & customary: The maximum fees insurers will consider for services provided by outof-network providers. Anything over and above may be billed directly to the participant.
Generic drugs: The same active ingredients as brand-name drugs, but generally are less expensive.
Preferred brand drugs: Brand-name drugs listed on the plan’s preferred list of prescription drugs.
Non-preferred brand drugs: Brand-name drugs that are not included listed on the plan’s preferred
list of prescription drugs.
Specialty drugs: Used to treat certain complex health problems. These drugs tend to be very
expensive and may be available only through specialty pharmacies. Additional rules may apply.
