Health Care 101


Confused about copays and coinsurances? Unsure about out-of-pocket costs and deductibles? You aren’t alone. Use the handy guide below to brush up on some common health insurance terms.

Deductible: This is the amount you pay for health care services and prescription drugs before your insurance starts to pay. Your deductible starts over at the beginning of each plan year. Not all plans have deductibles, and even those that do may pay for certain preventive services before the deductible is met.

Copay: This is the set amount you pay when you receive care or a prescription drug.

Coinsurance: This is the percentage of costs you pay when you receive care or a prescription drug.

Out-of-Pocket Costs: This is the amount you pay for health care services and prescription drugs that includes deductibles, coinsurance and copayments.

Maximum Out-of-Pocket Limit: Also called the MOOP, this is the most you will have to pay each year for services. Unlike Original Medicare-only plans that don’t put a cap on your annual costs, Blue Advantage gives you the peace of mind of knowing the maximum you will pay for medical care during the year.

Formulary: This is the list of medications that are covered by your plan. You can use the formulary to find out if the medications you take are covered and at what cost to you. The formulary can also be helpful when working with your doctor to decide which medications can help treat you while also keeping your costs as low as possible.

Tier: The drugs we cover are grouped into categories called tiers. The tiers go from preferred generics to specialty drugs, with the cost to you increasing with each tier. The drug tier also determines if you will pay a copay or coinsurance for your medication.

Generic Drugs: These have the same active ingredient as the brand-name version of the drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs. If your brand-name drug is not listed in our formulary, it may be listed in its generic form. Check with your doctor or pharmacy to see if a generic is available.

Prior Authorization, Quantity Limits, Step Therapy: These are additional requirements or limits on coverage that may apply to some medications. You can check the formulary to see if any of these apply to your medications and to learn how they work.

We hope this helps clear up some of the confusion. Something you should never be confused about is the value and security you get with your Blue Advantage plan.

Want to Learn More About Your Coverage?

You can always log in to your online account or visit the Plan Overview page to find the Annual Notice of Change, Evidence of Coverage and Summary of Benefits for your plan. Click the button below to view these helpful documents and to learn more about your plan.

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Call us at: 1-866-508-7145 (TTY 711). Our phone lines are open 8 a.m. to 8 p.m., 7 days a week from October - March and 8 a.m. to 8 p.m., Monday - Friday from April - September

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