Crohn’s & Colitis Glossary

Appeal

A request to a health insurance plan to review a decision denying a benefit, service, or payment.

Claim

A request for payment submitted to your health insurance plan for services you received.

Coinsurance

Your share of the costs of certain medical care or medications, calculated as a percentage of the total cost. For example, if the health insurance planallowed amount for an office visit is $100 and you've met your deductible, your coinsurance payment of 20 percent would be $20. The health plan pays the rest of the cost.

Copay Accumulator

A feature or program within a health insurance plan where the manufacturer's payments are no longer applied toward the patient's deductible or out-of-pocket expenses. The manufacturer copay card/coupon funds prescriptions until the maximum value on the coupon/card is reached. After the value is reached, your out of pocket-costs begin counting toward their annual deductible and out-of-pocket maximum.

Copay Maximizer

A feature or program within a health insurance plan where the manufacturer's payments are no longer applied toward the patient’s deductible and out-of-pocket maximum. The maximum value of the manufacturer's coupon/card is applied evenly throughout the benefit year.

Copayment

A fixed amount you pay for certain medical care or medications. The amount can vary by the type of health care service.

Deductible

The amount you pay for health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won't pay anything until you've spent $1,000 on medical care or medications. Deductibles reset annually. Keep in mind that some services, including preventive services, may not be subject to the deductible so be sure to check your plan carefully.

Drug Formulary

A list of medications covered by your pharmacy benefits. Formularies often have tiers with different levels of cost-sharing or coinsurance assigned to particular medications or therapies. Cost-sharing assigned to a higher tier typically cost more than those assigned to lower tiers.

Explanation of Benefits

A statement sent by a health insurance plan detailing what medical treatments and/or services were paid for on behalf of the covered individual.

High Deductible Plan (HDP)

A health insurance plan that usually has lower premiums and a high deductible – where you pay all of your healthcare costs until you meet your deductible and then the insurer pays a portion of your costs. This is usually combined with a health savings account (HSA). A high deductible plan may be an HMO, POS, PPO, or EPO plan.