Deductible - The amount that you have to pay before the payer begins to share the costs., Co-pay - The fixed amount that you pay for routine services., Co-insurance - The percentage that you pay for services., Out of Pocket Maximum - The total amount you pay each year for healthcare services., Coordination of Benefits - How multiple insurance plans for a patient work together to pay claims., Medicare Part A - Covers inpatient hospital stays for Medicare patients., Medicare Part B - Part of Medicare that covers doctor's services, outpatient care, and preventive services., Medicare Part C - Also called Medicare Advantage, and includes hospital, medical, and sometimes prescription coverage., Medicare Part D - Prescription drug coverage for Medicare patients., Medigap - Also called Medicare Supplement plans, and helps to fill the "gap" left by Traditional Medicare., Low Income Subsidy (LIS) - "Extra Help" for lower income patients with Medicare Part D that helps with paying those prescription costs., Medicaid - Government insurance administered at the State Level for lower income individuals and families., Dual Eligibility - When a patient is enrolled in both Medicare and Medicaid., Prescription Drug Tiers - Levels that determine the prescription drug co-pay that a patient will be responsible for., Pharmacy Benefit Manager (PBM) - Third-party administrator primarily responsible for processing and paying prescription drug claims., Formulary - A list of covered medications., Benefit Investigation - Determines expected medical or prescription drug coverage through the patient’s health insurance plan, Healthcare Common Procedure Coding System (HCPCS) - Often identified as a J-Code, and used to identify and bill for drugs, CPT Code - Used to report medical procedures and services for processing claims., International Classification of Diseases (ICD) Code - Also called Diagnosis Codes, and can be used for billing and reimbursement purposes, Prior Authorization (Precertification) - Required prior approval from a patient's insurance company before providing certain medical services or medications, Step-edit (Step-therapy) - Plan requirement to try a cheaper alternative before "stepping up" to the more expensive medication/therapy.,

Benefit Breakdown

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