It's Your Choice 2013 - Decision Guide (ET-2128d-13) - ETF

Glossary
Participant: The subscriber or any of
his/her dependents who have been
specified for enrollment and are entitled
to benefits.
PBM (Pharmacy Benefit Manager): The
third-party administrator that the Group
Insurance Board contracts with to
administer prescription drug benefits.
PCP (Primary Care Physician/Provider):
The PCP coordinates access to your
health plan’s coverage and services.
Your PCP works with you and other
medical providers to provide, prescribe,
approve and coordinate medical care.
PDP (Prescription Drug Plan): A
prescription drug plan that provides
Medicare Part D coverage to
Medicare-eligible participants covered
under an annuitant contract.
Physician Services: Health care services
a licensed medical physician (M.D.
– Medical Doctor or D.O. – Doctor of
Osteopathic Medicine) provides or
coordinates.
Plan Benefits: Comprehensive health
care services and prescription drug
benefits that your health plan provides
to its members in accordance with the
contract language.
Plan Provider: A medical provider who has
a contract with your health insurer or plan
to provide services to you at a discount.
Plan Service Area: The geographic
area in which a health plan provides
coverage through its network.
PPO (Preferred Provider Organization):
A health plan that uses a network
of doctors, clinics, hospitals and
other medical providers in a specific
geographic area, and also provides
coverage outside of that network (at
a higher out-of-pocket cost to the
member). This arrangement can be
attractive to participants who are
generally satisfied with the health plan’s
providers, but who may occasionally
need to use a particular specialist or
need additional options while traveling.
Currently, the only available Alternate
Health Plans that offer a PPO are WPS
Metro Choice and WEA Trust PPO.
Preauthorization: A decision by your
health insurer or plan that a health care
service, treatment plan, prescription
drug or durable medical equipment is
medically necessary. Sometimes called
prior authorization, prior approval or
precertification. Your health insurance
or plan may require preauthorization
for certain services before you receive
them, except in an emergency.
Preauthorization isn’t a promise your
health insurance or plan will cover the
cost.
Premium: The amount that must be
paid for your health insurance or plan.
You and/or your employer usually pay it
monthly, quarterly or yearly.
Prescription Drug Coverage: PBM
coverage that helps pay for prescription
drugs and medications.
Prescription Drugs: Drugs and
medications that by law require a
prescription.
Decision Guide Page 92