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Glossary of Terms

The terms [underlined/highlighted/in bold] throughout this site are defined below.

Brand-Name Drug

A prescription drug protected by trademark registration.

Coinsurance

A percentage of a covered expense; also, your share of a covered expense. For example, if the plan pays benefits at 90%, your coinsurance is 10%.

Consumer-directed health plan

A high-deductible health plan that combines traditional medical coverage with a special fund that pays first for covered expenses.

Copay/Copayment

A flat fee you pay for certain covered services, which represents a portion of the actual expense to the plan.

Deductible

The amount of your covered expenses you pay out of your own pocket before the plan starts to pay benefits.

Dependent

A person you claim as a dependent on your tax return, such as a spouse or dependent child.

Emergency

A recent and severe medical condition - including but not limited to severe pain - which would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:

  • Placing the person's health in serious jeopardy; or
  • Serious impairment to bodily function; or
  • Serious dysfunction of a body part or organ; or
  • Serious jeopardy to the health of the fetus (in the case of a pregnant woman).

Formulary

A list of prescription drugs that have been evaluated and selected by Aetna or Anthem Blue Cross and Blue Shield clinical pharmacists for their therapeutic equivalency and efficacy. The formulary includes both brand-name drugs and generic drugs and is periodically reviewed and modified by Aetna or Anthem Blue Cross and Blue Shield.

Fund (also Health Reimbursement Account)

An account set up and contributed to by Crawford and used to pay your covered expenses throughout the year until it is empty. Amounts paid from the fund also are applied to the deductible. You pay any remaining deductible amount once the fund is empty. Any amounts left in the fund are rolled over and added to Crawford's contribution for the following year.

Generic Drug

A prescription drug that is not protected by trademark registration, but is produced and sold under the chemical formulation name.

Health Reimbursement Account (HRA, also Fund)

An account set up and contributed to by Crawford and used to pay your covered expenses throughout the year until it is empty. Amounts paid from the HRA also are applied to the deductible. You pay any remaining deductible amount once the HRA is empty. Any amounts left in the HRA are rolled over and added to Crawford's contribution for the following year.

In-Network Provider (Aetna HealthFund HRA, Aetna PPO)

A doctor, hospital or other health care provider that belongs to Aetna's network.

Non-preferred Provider (Anthem Blue Cross and Blue Shield PPO)

A doctor, hospital or other health care provider that does not belong to the Anthem Blue Cross and Blue Shield network.

Out-of-Network Provider (Aetna HealthFund HRA, Aetna PPO)

A doctor, hospital or other health care provider that does not belong to Aetna's network.

In-network Provider (Anthem Blue Cross and Blue Shield PPO)

A doctor, hospital or other health care provider that belongs to the Anthem Blue Cross and Blue Shield network or in California, the Blue Cross network.

Primary Care Physician (PCP)

A doctor who coordinates a person's complete care, providing basic, routine services as well as referrals to specialists. A PCP can be an internist, general practitioner, family practitioner or pediatrician.

Transition Coverage

Transition coverage provides for a temporary bridge when you become a member of an Aetna medical plan if you are using out-of-network providers for treatment of special medical conditions. You must be in an active course of treatment with a non-participating provider to qualify for transitional coverage. Transition of Care coverage facilitates minimal disruption and permits the member to continue his/her treatment for a transitional period of time, without penalty.

Transition benefits are meant to apply to situations that are unstable or require intense medical attention for a relatively short period of time. Transition benefits are payable only with the prior approval of Aetna.

Examples of typical medical conditions eligible for transition level benefits include:

  • Pregnancies in the third trimester or high risk
  • Members receiving chemotherapy or radiation therapy
  • Member receiving outpatient intravenous therapy for a resolving condition
  • Members with a terminal illness with an anticipated life expectancy of six months or less
  • Members who are in the process of staged surgeries, for example cleft palate repair
  • Members who are in a post operative period
  • Members who are a candidate for organ or bone marrow transplant

There are many conditions that do not apply for transition coverage. If you think you have a condition that may qualify, please contact Aetna's customer service department at 1-888-282-4172 to request a Transition Coverage Request Form. You must receive Aetna's approval for transition coverage prior to receiving services from an out-of-network provider.