Medical deductibles and out-of-pocket maximums are two types of annual cost limits within your health coverage. Typically, you pay your deductible first. Every in-network out-of-pocket cost is applied toward your deductible. Once you meet your deductible amount, you will continue to pay out-of-pocket costs (such as copayment for doctor visits) until you reach your out-of-pocket maximum. Healthy Members usually do not reach this limit, but if you do, your insurance will cover 100% of your covered benefits for the rest of the calendar year.

A primary care provider (PCP) is trained to manage all of your health conditions. Your PCP plays many roles: primary care giver, health care advisor and consultant, coordinator of specialty care, patient advocate, and medical home. Some visits to your PCP such as a well-woman exam will require zero co-payment, regardless of the type of plan you have. Otherwise, you will either have to pay out-of-pocket or pay a copay for the visit.

Outpatient surgery doesn’t require a prolonged stay at a care facility. You are typically allowed to leave the hospital the same day. It tends to be less expensive than inpatient surgery, since it uses fewer of the hospital’s resources. The costs associated with the facility itself and the physician/surgeon performing the outpatient surgery are often treated as two different coverage benefits. 

Inpatient surgery requires one or more days of overnight stay at a hospital. Health insurance plans require you to be formally admitted into a hospital for a stay for a service to be considered inpatient. Typically, inpatient care is broken into hospital fees and physician/surgeon costs. Copays are usually calculated on a per-stay or per-day basis.

Medical imaging includes diagnostic tests such as ultrasounds, x-rays, MRIs, and CT scans. They are typically requested by physicians to help pinpoint medical problems. The cost of medical imaging tests varies by type of exam, where it’s performed, and what type of health insurance you have. 

A prescription drug is a pharmaceutical drug that legally requires a medical prescription to be dispensed. The drugs can vary from an antibiotic prescribed for an infection to drugs prescribed for chronic illness. Costs for prescriptions drugs vary dramatically. Most are available in generic, preferred brand, or non-preferred brand formulations. Specialty drugs are typically high cost.

Mental and behavioral health refers to the care of such conditions as substance abuse, depression, neurological disorders, addiction, and other issues that can negatively affect a person’s well-being and quality of life.