Understand Your Plan

A copay (or copayment) is the flat dollar amount that you pay for an office visit to an in-network provider or for a prescription drug. It does not count towards your deductible. Copays can be different for each plan or service.

The deductible is the annual amount you need to pay out of your pocket for covered health expenses before your plan begins paying a percentage of your costs. It can be different depending on where you seek treatment.

For example if your deductible is $1,000 and your first covered medical bill for the year is $1,500, you will pay all of the first $1,000, but only a percentage of the next $500 (and each additional bill that year). That percentage is determined by your coinsurance.

Coinsurance is the percentage of the total medical bill that you must pay after you have met your deductible for the year. For example, if you have a 25% coinsurance and you receive a bill for $500 (after deductible has been met), you would only pay $125. Coinsurance is different for each plan.

Ultimately, the amount you spend on coinsurance in a given year is limited by your plan’s out-of-pocket maximum.

Every medical plan has an annual out-of-pocket maximum for in-network services. This is the most you will pay each year in deductibles, copays, and coinsurance. There is also an out-of-pocket maximum for prescription drugs for each plan, separate from its medical out-of-pocket maximum.

Bear in mind that the out-of-pocket maximums for out-of-network providers are higher in the PPO and POS plans, and there are NO out-of-pocket maximums for out-of-network providers in the EPO plan.

Each prescription plan has its own list of brand name drugs, called a “formulary”. Your costs for brand name drugs are lower when you choose drugs on this list. Alternately, non-formulary drugs are those that are NOT on the list.

A single doctor who coordinates your medical care. If you enroll in the POS plan, it is recommended that you select a PCP. You may choose different PCPs for each of your dependents.

Also known as “evidence of insurability” (EOI) or “statement of health” (SOH), proof of good health is medical evidence provided to the insurance company that you are in good health. Proof of good health is sometimes required for Life Insurance and is not required to obtain medical coverage. For more details on the type of SOH required, please speak with MyHR.

When your doctor recommends certain procedures, your plan requires him or her to pre-certify these procedures with the plan to ensure you are covered for the service. In network, your providers can obtain pre-certification on your behalf; out-of-network, you must obtain it yourself.

You can pre-certify a treatment by calling the number on the back of your medical plan ID card. If you do not get pre-certification for a treatment that requires it before undergoing the treatment, you will pay a penalty.