Here is a glossary of some of our most-used terms:
A prescription drug that has been patented and is only available through one manufacturer. Newer drugs are usually available only as brand-name drugs. A brand-name drug may have a generic equivalent after the original patent expires.
The percentage or amount you are required to pay for reasonable medical expenses after you reach your deductible. For example, you may pay 20% and CareFirst will pay 80% of the cost for the services you need. If you use providers in CareFirst’s network, your costs are based on our discounted rates.
Also called a copay. The set dollar amount you pay for a covered health service. For example, a visit to your primary care physician may cost you a $20 copay, or a $30 copay for a specialist and a $15 copay for a prescription. You are responsible for the copays and CareFirst covers the rest. Please note that copays are due at the time of service.
The deductible is the amount you are responsible for before CareFirst starts paying your claims for covered services. For example, if your plan has a $500 deductible, you need to pay the first $500 of costs for medical services you receive. Once your deductible amount is reached, CareFirst begins to pay a portion or all of your health care costs up to the out-of-pocket maximum, depending on the plan.
These drugs are the pharmaceutical equivalent to one or more brand drugs and meet the same standards of safety, purity, strength and effectiveness as the brand drug. They usually cost less than brand drugs and are rated by the U.S. Food and Drug Administration (FDA) to be as safe and effective as brand drug.
Blue Cross Blue Shield negotiates fees and signs agreements with health care providers and facilities, creating a network of providers. “In-network” refers to the providers who participate in our network. We encourage you to use participating in-network providers, since you’ll generally pay less for copayments and deductibles.
These providers are not part of the respective Blue Cross Blue Shield PPO networks. Members enrolled in Preferred Provider Organizations (PPO) can go out-of-network, but will pay higher out-of-pocket costs.
The maximum amount you pay for allowed medical and pharmacy expenses before CareFirst covers services at 100%. Please note: This may or may not include your deductible.