Co-insurance is the percentage of a dollar amount that you pay for certain services. Unlike a fixed co-pay, co-insurance varies, depending on the total charge for a service. The amount you pay in co-insurance (for eligible services) will count towards your out-of-pocket maximum.

A co-pay is a flat dollar amount that you pay for certain services like office visits and prescriptions.

An annual deductible is the fixed dollar amount you must pay each year for services that require co-insurance before the plan pays any benefits.

The drug list is a list of covered drugs. The listing includes generic and preferred brand drugs covered by the plan. This list is often called a formulary.

The drugs covered by the State’s pharmacy benefit are grouped into three tiers — generic, preferred brand and non-preferred brand. Each tier has a different co-pay amount.

Under a fully insured plan, an insurance company, rather than a group sponsor (like the State) pays all claims. The sponsor pays a premium to the insurance company. The State’s dental plans are fully insured.

A generic drug (also called tier one) is a Food and Drug Administration (FDA) approved copy of a brand name drug. A generic medicine is equal to the brand name product in safety, effectiveness, quality and performance. You pay the least when you fill a prescription with a generic drug.

The Health Insurance Portability and Accountability Act (HIPAA) is legislation that protects health insurance coverage for individuals who lose or change jobs and establishes a privacy rule and national standards for protecting personal health information. HIPAA means your personal health information can’t be shared without your consent and protects your privacy.

In-network care is provided by a network provider. Costs for in-network care are usually less expensive than out-of-network care as a result of special agreements between insurance carriers and providers.

The maximum allowable charge (MAC) most that a plan will pay for a service from an in-network provider. If you go to an out-of-network provider who charges more than the MAC, you will pay the difference between the MAC and the actual charge.

Meeting your deductible means you have reached your annual deductible. This is the amount you pay each year before the plan pays benefits. It applies to hospital charges and other services that require co-insurance. It does not apply to services with a co-pay such as a visit to your primary care physician or to prescription drugs.

A network is a group of doctors, hospitals and other health care providers contracted with a health insurance plan to provide services to plan participants at pre-negotiated (and usually discounted) fees.

A non-preferred brand drug (also called tier three) belongs to the most expensive group of drugs. You will pay the most if your prescription is filled with a non-preferred brand.

Out-of-network care refers to health care services from a provider who is not contracted with your insurance carrier. Costs for out-of-network care are usually more than for in-network care. The benefits paid are usually based on the maximum allowed by the plan. When out-of-network charges are higher than the maximum allowed, the member pays the difference.

An out-of-pocket maximum is the most you will pay for your deductible and co-insurance each year. The out-of-pocket maximum does not include premiums or co-pays. Once you reach your out-of-pocket maximum, the plan pays 100 percent of covered medical expenses that require coinsurance for the rest of the year.

A preferred brand drug (also called tier two) belongs to a group of drugs that cost more than generics but less than non-preferred brands.

A PPO gives plan participants direct access to a network of doctors and facilities that charge pre-negotiated (and typically discounted) fees for the services they provide to members. Plan participants may self-refer to any physician or specialist in the network. The benefit level covered through the plan typically depends on whether the member visits an in-network or out-of-network provider when seeking care.

Typically, members are required to pay a prescription drug co-pay when filling a prescription. This is the fixed dollar amount you pay, such as $25 per prescription. The co-pay is lowest for a generic, higher for a preferred brand and highest for a non-preferred brand.

Preventive care refers to services or tests that help identify health risks. For example, preventive care includes mammograms, annual wellness exam/physical and immunizations as well as regular blood pressure checks. In many cases, preventive care helps a patient avoid a serious or even life-threatening disease.

Primary Care Physician (also known as PCP) refers to your regular medical doctor. This is the physician you see most often. A PCP can be a general practitioner, a doctor who practices family medicine, internal medicine, OB/GYN or pediatrics or a nurse practitioner or physician’s assistant.

Under a self-insured plan, a group sponsor (like the State) or employer, rather than an insurance company, is financially responsible for paying the plan’s expenses, including claims and plan administration costs. The state’s health insurance plans are self-insured.