Back to top Active full-time employee
Person that works a normal workweek for an employer at a minimum number of required hours.
Back to top Coinsurance
Requires payment of a percentage of the cost of the medical services. Most plans require either a coinsurance or copay: usually not both.
A flat fee charged each time you visit the doctor or use certain medical services regardless of the cost of the procedure. Doctor visits and pharmaceutical purchases are often subject to copays.
Back to top Deductible
Money paid out-of-pocket each year before medical plan coverage begins. Each family member usually has a separate deductible to meet.
A person who is covered by another person’s plan. It can be a child, spouse or domestic partner.
Back to top Emergency
A serious illness or condition that comes on suddenly and needs immediate medical care.
Explanation of Benefits (EOB)
A detailed document provided by an insurance carrier outlining the charges, payments and balances of processed claims.
Back to top Health Savings Account (HSA)
An account that can be used to pay for covered health care costs or can be saved for future health care costs. Plan members must be covered by a high deductible health plan to qualify for an HSA.
High-Deductible Health Plan (HDHP)
A plan that meets Federal regulations and has a higher deductible than standard health plans allowing participants to utilize a health savings account (HSA).
Back to top Mail Order Pharmacy
Service available through Aetna Rx Home Delivery® that allows members to save time and money with a three-month supply of certain prescriptions delivered directly to their home.
Back to top Network
A group of health care providers including doctors and hospitals that are contracted with the carrier. For Aetna health plans, choose the Open Choice PPO Network.
Back to top Out-of-pocket maximum mandate
All cost sharing must apply toward the out-of-pocket maximum including in-network medical, behavioral health and pharmacy cost sharing. Does not include premiums, balance billing amount of non-network providers or spending for non-covered services. The out-of-pocket maximum must include copays, deductibles, and coinsurance.
Over-the-counter drugs (OTC)
Drugs that can be purchased without a prescription and are not covered under the Rx benefits of the plan.
Back to top Precertification
Approval required for certain care, admission or procedures that must be completed prior to event taking place. Precertification can also be called:
The amount you pay for your insurance policy. Premiums are often deducted from your paycheck.
Preventive or Preventative Care
Services that can help prevent certain diseases and illnesses. Generally includes annual exams, immunizations and testing for certain diseases.
Back to top Qualifying Event
An event that allows a member to change his or her health benefits. Some examples include death, job loss, divorce, marriage and the birth of a child.
Back to top Renewal
A designated time of year when the policy continues but with updated terms such as new rates.
The common symbol describing prescription or pharmacy.
Back to top Specialist
A provider that is trained in a specific medical area such as a dermatologist or cardiologist.
A provision requiring members to try certain drugs prior to a particular brand name drug being paid for under the plan.
Back to top Urgent Care
Care provided for sudden illness or injury that is not life threatening but requires care to be sought quickly so the person does not develop a more serious problem.