Coinsurance
The percentage of eligible claims you pay after you meet your deductible.
Coinsurance Maximum
The most you will have to pay in a year in coinsurance for covered benefits after you meet your deductible. Once you reach your coinsurance maximum, you will still pay office visit and prescription copays.
Copay
The fixed, up-front dollar amount you pay for certain covered expenses. Office visit copay amounts do not apply toward your deductible or coinsurance maximum.
Deductible
The up-front, out-of-pocket expense. Participants must meet their deductible with eligible charges before claims will be paid.
Deductible for Employee + Dependent(s) Coverage
This applies to an employee who has dependents included on his/her coverage. You and your dependents are responsible to pay for medical and prescription drug claim costs up to the plan’s family deductible amount before GuideStone begins paying claims for anyone in the family. The family deductible may be met by one individual or by multiple family members’ combined claims. This is known as an “aggregate” or combined deductible.
Deductible for Employee-only Coverage
This applies only to an employee who has no dependents included on their coverage. You are responsible to pay for medical and prescription drug claim costs up to the plan’s individual deductible amount before GuideStone begins paying claims.
Emergency Care
Medical services from the emergency department of a hospital to evaluate a medical condition that in the absence of immediate medical attention would place the health of the individual in serious jeopardy; cause serious impairment to bodily functions; or cause serious and permanent dysfunction to any bodily organ or part.
Family Deductible
When family members meet the plan amount determined to be the family deductible, the plan will consider all family members to have met their deductibles. One individual cannot contribute to the family deductible more than the amount determined to be the individual deductible (this is an embedded deductible).
Generic
A term used for prescription drugs identified by their chemical name. A bioequivalent to the brand-name drug made available to the public after the patent has expired on the brand-name drug. The generic version usually results in a less expensive drug.
Individual Deductible
When an individual meets the plan amount determined to be the individual deductible, the plan will begin paying claims for that individual at the coinsurance level.
In-network
Health care services received from a provider in a network.
Mail Order
When you need a prescription drug on an ongoing basis, you can mail your prescription to the Medco by Mail™ service to receive prescriptions for up to a 90-day supply of medication.
Network Provider
A doctor, hospital or other healthcare facility that has entered into a contract to provide medical services or supplies at agreed-upon rates to you or your covered dependents under the plan.
Non-preferred Drugs
A list of prescribed medications that are not on the plan’s formulary.
Preferred Drugs
Also known as formulary drugs; this is a list of commonly prescribed, brand-name medications that are selected based on their clinical effectiveness and opportunities to help control your plan’s costs.
Primary Care Physician Copay
The amount you pay for an office visit to a network primary care physician such as a pediatrician, general practitioner, family practitioner, internist or gynecologist.
Retail Pharmacy Benefits
When you need a prescription on a short-term basis, you can fill your prescription at a local participating network pharmacy to receive prescriptions for up to a 30-day supply.
Specialist
Any physician not considered a primary care physician.
Wellness and Preventive Care
Covered services are based on Highmark’s preventive health schedule for GuideStone.