Glossary
Below are definitions of some terms that are used in this web site:
Co-insurance: when you pay a percentage of medical charges
instead of a fixed amount.
Co-pay: when you pay a fixed dollar amount for a medical service.
Deductible: the amount you pay each year toward certain covered
medical expenses before your plan starts paying benefits.
Formulary: a preferred list of commonly prescribed medications
that are selected based on their clinical effectiveness and
opportunities to help contain costs within a prescription
drug program. Non-formulary drugs are any drugs not found on
this list.
Health Maintenance Organization (HMO): a type of health
plan that consists of a network of doctors, hospitals, and other
health care providers. This type of plan will not pay for an outof-
network provider except in emergency situations. Unlike
traditional HMOs, with Duke Select, Duke Basic, and Blue
Care, you do not need a referral from your Primary Care
Physician (PCP) to see a network specialist.
Maintenance Medications: medications that a provider has
prescribed for regular (i.e., daily) use and include (but are not
limited to) heart/ulcer/blood pressure medication, hormone
therapy, and birth control pills.
Network: a group of doctors, hospitals, and other providers that have contracted with
an HMO or PPO and have agreed to accept a lower percentage of usual, customary,
and reasonable (UCR) rates.
Out-of-Pocket Expense: the amount you pay towards a medical service that isn't
reimbursed by your insurance plan.
Preferred Provider Organization (PPO): a type of health plan that consists of a
network of doctors, hospitals, and other health care providers. You may visit doctors
outside of this network for most services. If you use an in-network provider, you will be
responsible for a lower portion of the bill than you would if you used an out-of-network
provider.
Primary Care Physician (PCP): a health care provider (such as a nurse practitioner,
physician, or physician assistant) who belongs to a network and who provides primary
medical care in internal medicine, pediatrics, family practice, and/or general practice.
Usual and Customary: This refers to the standard or most common
charge for a specify medical service when rendered in a particular geographic area.
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