University of Toledo 2027 Open Enrollment

Below are commonly used terms that may help you understand healthcare plans and other materials related to your benefits.

Co-insurance – a percentage you pay for medical services other than office visits after the deductible is met. (Example: 80/20 plan: the plan will pay 80% and you will pay 20%.)

Co-pay – a fixed amount you pay at an office visit; the co-pay does not count towards the deductible.

Deductible – an amount you pay before insurance benefits will begin paying.

Excluded services –services not be covered by the insurance plan. You will have to pay for the entire cost of these services.

Flexible Spending Account (FSA) – a tax-free account that you can use to pay for medical expenses. Money left at the end of the year is lost.

Health Savings Account (HSA) – a tax-free account that you can use to pay for medical expenses. It carries over from year to year and consists of both your and your employer’s contributions.

Open enrollment – a set period every year when you elect benefits for the following year without a qualifying life event.

Premium –the amount you pay for insurance coverage.

Prior authorization –services that must be approved by the insurance company before you receive care. If pre-authorization is not obtained, the service may not be covered and you could be charged for the entire amount of services delivered! Healthcare providers will sometimes obtain pre-authorization for you, but it still is always your responsibility to check first with your insurance company before you receive healthcare services.

Qualifying life event – a life event that allows you to change your benefit during the year (e.g., marriage, divorce, birth of a child, loss of other coverage, etc.).

Summary of Benefits and Coverage (SBC) – a brief, easy-to-understand summary of your plan’s coverage. It is intended to be a uniform document that enables you to compare plans.

Summary Plan Description (SPD) – a booklet explaining your benefits, eligibility requirements, pre-authorization requirements, plan exclusions and other relevant details.

Tier 1 –these providers generally include University of Toledo Medical Center and UT Physicians.

Tier 2 –in-network providers.

Tier 3 –out-of-network providers.

Prescription Drugs / Pharmacy Benefits

Co-insurance – a specified percentage of the cost of the drug or service that you are responsible to pay. (Example: Depending on your plan, perhaps 20% of the total cost of your prescription medications.)

Compounded medications – medications not made or packaged to be dispensed at a traditional pharmacy. They are made based on a healthcare provider’s prescription, and individual ingredients are mixed together in the exact strength and dosage form required by the patient.

Co-pay – a pre-determined amount you pay for each medication or medical service you receive; not related to the cost of the medication or service. (Example: A $7 co-pay for generic medications —regardless of its entire cost, and a $15 co-pay for brand name prescription medications— regardless of its entire cost. If your prescription actually totals $85 for a name brand drug, you still would pay only $15 for that name brand drug each time you get it refilled.)

DAW – an abbreviation for “Dispense as Written.” This is used when a doctor decides you should receive a brand name medication even though a generic form of that drug is available. A special notation from the doctor is required to qualify.

Deductible – the maximum dollar amount you will pay each calendar year before your insurance plan begins covering certain costs. (After reaching your deductible, you are still responsible for copays.)

Formulary – a list of medications that are covered under your prescription plan.

Generic drug (Tier 1 drug) – a generic medication that contains the same active ingredient as a brand name drug. It usually is considered identical in efficacy, safety, side effects and dosing. It costs significantly less than their brand name counterparts.

Maximum out-of-pocket – the maximum dollar amount you are responsible for within a calendar year.

Non-preferred drug (Tier 3 drug) – a brand name medication that is considered non-preferred. This usually means there is a preferred alternative (and less expensive drug) within Tier 2.

Preferred brand drug – a brand name drug that has a trade name and is protected by a patent. This means that only the company holding the patent may sell or produce the medication for a specified amount of years.

Prior (or pre-) authorization – a process that requires a prescriber (your healthcare provider) to complete paperwork for the insurance company’s review before the prescribed medication will be covered under your prescription plan.

Prior authorization list – a list of medications that would need to undergo a prior authorization in order to be covered under your prescription benefit.

Dental Benefits

Dental care major services – dental services beyond basic, routine services, such as dental surgery, root canals, treatment for gum disease, crowns, bridges and dentures.

Dental care preventive services – routine dental services, such as cleanings, exams and X-rays