XYZ Company, Inc' Blue Cross Blue Shield Medical Insurance Terms and Definitions

1
XYZ Company, Inc.Blue Cross Blue Shield
Medical Insurance Terms and Definitions

• Calendar Year Your benefit period from January
  1st to December 31st.
• Coinsurance (Stop loss Maximum) In property
  insurance, requires the policyholder to carry
  insurance equal to a specified percentage of the
  value of property to receive full payment on a
  loss. For health insurance, it is a percentage of
  each claim above the deductible paid by the
  policyholder. For a 20 percent health insurance
  coinsurance clause, the policyholder pays for the
  deductible plus 20 percent of his covered losses.
  After paying 80 percent of losses up to a
  specified ceiling, the insurer starts paying 100
  percent of losses.
• Co-pay - A small fixed amount required by a
  health insurer to be paid by the insured for each
  outpatient visit or drug prescription. Your
  copay includes services performed in physician
  office, including lab x-ray. Preventative Care
  including Routine Physicals, Well Baby Exam, and
  Vision Hearing Exams, Immunizations thru age 7
  (deductible is not applicable to immunizations of
  a Dependent Child age 7 years of age or younger).
  Office Outpatient Surgery, Inpatient Visits /
  Surgery Certain Diagnostic Procedures Maternity
  Care. Copay is applied toward meeting
  coinsurance stop loss maximums and continues
  after coinsurance maximums are reached.
  Prescription Drug Program copay will not satisfy
  coinsurance maximum.

2
XYZ Company, Inc. Blue Cross Blue Shield
Medical Insurance Terms and Definitions

• Deductible The amount of loss paid by the
  policyholder. Either a specified dollar amount, a
  percentage of the claim amount, or a specified
  amount of time, that must elapse before benefits
  are paid. The bigger the deductible, the lower
  the premium charged for the same coverage.
• Eligible Dependents Spouse or child(ren) of the
  immediate family of the employee. Dependent
  unmarried children are covered until age 25.
  Disabled dependent children can be covered beyond
  age 25. There is automatic coverage for newborn
  infants, for the first 31 days following birth.
  Infants not enrolled for coverage within the
  first 31 days after birth will be treated as a
  late enrollee.
• Prescription Drugs The most affordable drugs,
  that offers participants the lowest available
  copay. Generic Drugs are pharmaceutically and
  therapeutically equivalent to Brand Name Drugs.
  If there is no Generic Drug for your Preferred or
  Non Preferred Brand Name Drug Prescription
  Order, you will pay no more than the applicable
  Preferred or Non Preferred Brand Name Drug
  Co-payment Amount. If you receive a Preferred or
  Non Preferred Brand Name Drug when a Generic
  Drug is available, your payment amount will be
  the sum of (a) the difference between the
  allowable amount of the Preferred or Non
  Preferred Brand Name Drug and the cost of the
  Generic Drug, plus (b) the Preferred Brand Name
  Drug Co-payment amount. Your Generic Drug
  co-payment amount is currently 20 with your
  employer group health plan.

3
XYZ Company, Inc. Blue Cross Blue Shield
Medical Insurance Terms and Definitions

• Late Entrant - An employee that does not enroll
  within 30 days of their eligibility date. If an
  employee or a dependent is not enrolled in a
  timely manner they will not be eligible for
  coverage until the anniversary date unless they
  have a loss of coverage or qualifying event.
• Lifetime Maximum The maximum amount any carrier
  will pay base on your lifetime. Maximums include
  Network and Non Network.
• Network By visiting a provider (doctor or
  hospital) that is in the network, that provider
  has contraction ally agreed to see members at a
  discounted fee arrangement. With a PPO network
  you have the ability to go to any doctor or
  hospital, however you may want to stay within the
  Network to maximize your benefits and reduce your
  costs. Employees and their eligible dependents
  may seek care from network providers listed in
  the provider directory. When care is received
  from network providers, participants will receive
  network benefits (the maximum benefits available).

4
XYZ Company, Inc. Blue Cross Blue Shield
Medical Insurance Terms and Definitions

• Non - preferred Brand Name Drug Name Brand
  drugs have the highest copay. The Non
  Preferred Brand Name Drug tier includes a small
  number of therapeutic drug categories. Non
  Preferred Brand Name Drugs may not offer clinical
  or cost advantages over other drugs in the same
  therapeutic category. Your Non - Preferred Brand
  Name Drug co-payment amount is currently 50 with
  your companies group health plan.
• Out-of-Network - Providers (doctors and
  hospitals) who are not contracted with an
  insurance carrier and can charge whatever they
  feel is appropriate without guidelines. Your
  insurance carrier will reimburse the out of
  network provider at a rate the carrier feels is
  reasonable and customary. If there are any
  amounts over and above what the insurance carrier
  redeems is reasonable and customary it is the
  members responsibility to pay the provider the
  difference. Employees and their eligible
  dependents may seek care from providers outside
  the network (providers not listed in the provider
  directory) and receive outof-network benefits
  (the lower level of benefits).

5
XYZ Company, Inc. Blue Cross Blue Shield
Medical Insurance Terms and Definitions

• Pre-existing Conditions - Any physical and/or
  mental condition or conditions that you have
  received medical advice, diagnosis, care or
  treatment for during the 6 months prior to your
  enrollment date. If you have enrolled in the PPO
  Plan and you have had continuous health insurance
  coverage for the last 12 months, either with your
  previous coverage or another insurance company,
  pre-existing conditions will be covered. If you
  have NOT had continuous health coverage for the
  last 12 months or have had a break in coverage of
  at least 63 days, you will not be covered for
  pre-existing conditions until you have been
  covered by the previous plans and the new plan
  for a total of 12 months.
• Preferred Brand Name Drug - A drug that has a
  trade name and is protected by a patent (can be
  produced and sold only by the company holding the
  patent). Preferred Brand Name Drugs are
  available at slightly higher copay than Generic
  Drugs. The Preferred Brand Name Drug tier
  consists of the vast majority of high-quality
  branded drugs. Your Preferred Brand Name Drug
  co-payment amount is currently 35 with your
  companies group health plan.
• Provider Doctors, pharmacies and hospitals
  providing services to a member.

6
XYZ Company, Inc. Blue Cross Blue Shield
Medical Insurance Terms and Definitions

• Silicon Benefits offers a single contact for ALL
  of your insurance needs!
• By simply calling our office during normal hours
  we offer a live voice to ensure you are greeted
  with respect and that we solve your problem at
  your convenience. We are also available after
  business hours if there is a medical emergency or
  if that is the best time for you to talk. Of
  course our web site is open 24/7 and you can find
  lots of helpful information by visiting
  www.siliconbenefits.com
• We offer free consultation to the employer,
  administrator, and the employees of your
  organization. This allows you to point all
  insurance issues to our office for resolution,
  thus reducing the time you and your employees
  spend on solving issues with an insurance
  carrier, which can be very frustrating. We want
  to make your job easier!
• Please contact us with any questions toll free
  866.203.8333 or email canada_at_siliconbenefits.com