Getting to know the basics of Insurance Terminology and Drug Interaction


A sudden, unexpected or unforeseen event, unintended incident.

accidental death and dismemberment (AD&D) rider
An additional cash benefit to the insured or his/her beneficiaries if an accident causes either the death of the insured or causes the insured to lose any two limbs or the sight in both eyes, usually added as a supplement to most insurance policies.

A chemical that binds to a receptor of a cell and triggers a response by the cell. An agonist often mimics the action of a naturally occurring substance.

annual out-of-pocket maximum
A specified dollar amount set by the plan which the insured must pay out of his or her own pocket for covered expenses

The person or persons who applied for an insurance policy, may also be a business or business entity or behalf of their employees.



basic benefit policy
A health insurance policy that covers basic medical expenses, usually accompanied my major medical coverage

The individual or party, that the owner of a life insurance policy names to receive the policy benefit once the insured person is deceased.

brand-name (medications)
Prescription drugs or medications that are produced by the developer of the medication

A sales agent who is under contract to sell the insurance product or products of more than one insurance company or entity, usually paid on a commission bases.



calendar-year deductible
A specified amount that the insured person must pay before the insurer can make insurance payments for covered services, sickness or injury.

Carbidopa (Lodosyn)
A drug given to people with Parkinson's disease in order to inhibit peripheral metabolism of levodopa.

case management
A utilization management technique used to address whether care is medically necessary as well as provided suggestions on alternative treatments or solutions, especially when the patient is likely to require very expensive medical care.

certificate of insurance
A document that describes the type and length of coverage provided by a group insurance policy that is given to each insured by the group policyholder.

chiropractic care
Practitioners who manipulate the spine and other structures within the body to relieve pain and tension resulting from posture, stress or strain.

A request for payment under the terms of an insurance policy, usually resulting from an injury or sickness in which and insured person has received medical treatment

claim examiner
An insurance or claims company employee who is responsible for carrying out the claim examination process.

Splitting or spreading of risk between multiple parties, a specified percentage of the cost of treatment the insured is required to pay for all covered medical expenses remaining after the policy's deductible has been met.

The amount of money made by an insurance broker or insurance agent, usually a percentage of the premiums for selling an insurance policy to one or more individuals.

comprehensive major medical policy
A health insurance policy that covers both major medical coverage and basic medical expense coverage.

co pay
A specified fee that many insurance plans require an insured to pay for certain medical services, a specified amount that the insured must pay toward the cost of each prescription under a prescription drug plan.

covered accident
An accident that results from Injury or loss covered by the insured's insurance policy



A specified amount the insured is required to pay as provided by the applicable coverage under the insured's policy in the event an injury or sickness, also known as loss, an amount of covered medical expenses that an insured must incur before the insurer(Insurance Company) will make any benefit payments under a medical expense policy.

dental accident
Unexpected injury to the insured's tooth or teeth, usually covered under the insured insurance plan, dental coverage can be added for additional premium, usually optional

The known evaluation, diagnosis, prevention, and treatment of diseases, disorders and conditions of the soft and hard tissues of the jaw (mandible), the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body.

A person for whom the insured has some legal, financial or moral obligation

A legally qualified person licensed by the state in which he or she practices, a practitioner of the healing arts performing services within the scope of his or her license as specified by the laws of the residential state of such practitioner, a medically certified person or persons

domestic partner
Domestic partners are commonly defined as "two adults" who share an emotional, physical and financial relationship similar to that of a married couple, usually they choose not to marry or cannot legally marry, share a mutual obligation of support for the basic necessities of life, usually share common household space. (commonly described as being male/male, male/female, or female/female)

domestic student
A student classified as a United States Citizen or eligible Non-Citizen (Permanent Resident or Refugee)



effective date
The specified date of when the health insurance policy begins.

elective treatment
Medical treatment which is not necessitated by a pathological change in the function or structure in any part or parts of the body, occurring after the insured person's effective date of coverage. Treatment specifically requested by the insured, may include surgery

The symptoms must be sudden, severe and require immediate medical attention

emergency care
Treatment or services rendered on an urgent or immediate bases, usually in a hospital emergency room, extremely urgent medical service

emergency room visit (ER Visit)
A visit to a hospital for treatment of an accidental injury or sickness emergency medical care

employee contribution
The amount of premium the employer requires the employee to pay towards his or her health insurance coverage, may include a specified fee for the insured person's dependents who are also being covered

enrollment or eligibility period
The time during which a new group member may first enroll for group insurance coverage.

exclusions and limitations
Outlined conditions, situations and services not covered by the health plan.

Usual and Customary charges for "Medically Necessary Treatment", services or supplies, such expenses or charges shall not include any amount not customarily charged to persons without insurance

experimental care
Services or supplies that the insurer (Insurance Company) determine is not commonly and customarily recognized as being safe and effective for the particular diagnosis/treatment



fee schedule (limited fee schedule)
A fee structure used by insurers which the insurance company places limits on the dollar amounts that it will reimburse providers for covered medical procedures and services, both in and out-of-network if applicable.

Fee for service plan (indemnity plan)
A health insurance plan that allows the insured to use any medical provider that he or she chooses, no provider networks to utilize.

formulary drugs
A drug or drugs that have been thoroughly reviewed by a team of expert pharmacists and physicians; identified as safe, effective and beneficial to members for treating medical conditions.

fully insured plan
A group insurance plan for which an insurance company bears the responsibility of making all claim payments.

fully self-insured plan
A group insurance plan under which the employer, business or group takes complete responsibility for all claim payments and related expenses rather than purchasing coverage from an insurance company.



Gatekeeper (primary care physician)
A term used to describe the primary care physician's role, which is to authorize all services delivered to the insured by other physicians or health care providers. Thus, whenever you wish to see a physician other than your primary care physician, you must first obtain his or her permission (via a referral).

generic drug (generic drugs, short: generics)
A drug which is produced and distributed without patent protection. The generic drug may still have a patent on the formulation but not on the active ingredient.

generic (medications)
When a new drug is put on the market, the pharmaceutical company patents it under a brand name. The company has the exclusive right to sell the drug under this name, but once its patent expires, other companies can sell the same drug under its chemical, or generic, name. Generic drugs are typically cheaper than brand-name drugs, but the Food and Drug Administration requires generic drug manufacturers to show that a generic drug "delivers the same amount of active ingredient in the same time frame as the original product."

group term life
A life-insurance plan that provides employees with additional coverage at economical group rates.

guaranteed renewable policy
A health insurance policy that the insurer is required to renew -- as long as premiums are paid -- at least until the insured attains the age limit specified in the policy, or the policy is cancelled by the insured. The insurer may increase the premium rate for any class of guaranteed renewable policies.



health care provider
A doctor, hospital, laboratory, nurse or anyone else who delivers medical or health-related care.

health insurance
Is a type of insurance coverage for individuals to help protect them against unexpected medical cost, coverage whereby the insurer pays the medical costs of the insured if the insured becomes sick due to covered causes, or due to accidents. The insurer may be a private organization or a government agency.

health insurance portability and accountability act of 1996 (HIPAA)
Under this federal law (known as HIPAA), group health plans cannot deny coverage based solely on an individual's health status. This law also gives employees who change or lose their jobs better access to health coverage, guarantees renewability and availability to certain employees and limits exclusions for pre-existing conditions. For example, under this law, group health plans must credit any employee the amount of time that they spent on any health plan prior to the new plan, which is known as "prior credible coverage." A pre-existing condition will be covered without a waiting period when an employee joins a new group plan if the employee has been insured for the previous 12 months with credible health insurance, with no lapse in coverage of 63 days or more. This means that if an employee has been insured for 12 months or more, the employee will be able to go from one job to another and his or her pre-existing coverage will remain intact -- without additional waiting periods. However, if an employee has a pre-existing condition and was not covered previously for 12 months before joining a new plan, the longest the employee will have to wait for their pre-existing coverage to be covered is 12 months.

health maintenance organization (HMO)
A health care financing and delivery system that provides comprehensive health care for subscribing members in a particular geographic area using managed care techniques. Most HMOs require that you only utilize physicians within their network, often going so far as to require you to choose a primary care physician who directs most courses of your treatment.

home country
The country from which the insured person holds a passport, resides or has lived for most or all of his or her life

home health care
Skilled medical care and other health care services that you receive in your home for the treatment of an illness or injury. Some insurance plans don't provide this kind of coverage, or provide it only for a limited amount of time.

A facility which provides inpatient and outpatient services for the care and treatment of injured and sick people, it provides room and board as well as nursing services 24 hours a day, a convalescent home, it has established facilities for diagnosis and major surgery, it is supervised by a doctor, run under the laws of the jurisdiction in which it is located, does not include a facility specifically for alcoholics or drug addicts

hospital confinement
An extended or overnight stay of 18 or more consecutive hours as a resident or bed-patient



indemnity plan
Also called a fee-for-service plan. A health insurance plan that allows the insured to use any medical provider that he or she chooses. As such, there are no networks to utilize.

individual practice association (IPA)
A type of open-panel HMO that contracts with an association of physicians who agree to provide services for HMO members.

Bodily harm caused by an Accident which is solely the cause of loss. All injuries due to the same related cause are considered one injury

inpatient surgery
Medical procedures which require the patient to spend at least one night at the hospital. Most plans limit the amount of time an inpatient may stay at the hospital following surgery.

insurance agent
A person authorized by an insurance company to represent the company in its dealings with applicants for insurance.

insurance coverage
Is the equitable transfer of the risk of a potential loss, from one entity to another, in exchange for a premium, is a form of risk management primarily used when an investment is taken out specifically to reduce or cancel out the risk in another investment, usually against the risk of a contingent loss

insurance rate/premium
Is a factor used to determine the amount the insured person or Persons is responsible to pay in order to obtain coverage, the amount to be charged for a certain amount of insurance coverage.

The person or persons whose life or health is insured under an insurance policy. Also referred to as a "member."

In economics, is the company that sells the insurance.

international student
Is a student classified as a Non-Immigrant holding visa types "F" classified as a (Student), type "J" classified as an (Exchange Visitor), type "B" classified as a (Tourist), or type "A" classified a (Diplomat)

investigational care
Services or supplies which require approval by any governmental authority and such approval has been granted before the service or supply is furnished



is the location at which two or more bones make contact. They are constructed to allow movement and provide mechanical support, and are classified structurally and functionally



We apologize for the inconvenience, however, at this time we have no insurance or related glossary terms beginning with the letter "K".



The combination of carbidopa and levodopa and is used to treat Parkinson's disease[1] and Dopa-Responsive Dystonia (DRD). It is sold under several brand names, including Sinemet, Parcopa, and Atamet.

life dependent
This option is offered by some plans to provide a set amount of life insurance for the insured's spouse, domestic partner or children.

lifetime maximum
The maximum amount of money a plan will pay towards healthcare services over the course of the insured's lifetime.

medical expense covered by the Policy as result of injury or sickness as defined in the policy and other expenses as specifically covered



major medical insurance plan
A type of traditional medical expense coverage that provides substantial benefits for hospital surgical expenses and physicians' fees.

managed care
A method of integrating the financing and delivery of health care within a system that seeks to manage the cost, accessibility and quality of care.

maternity coverage
Many individual plans and some small-group plans for groups of fewer than 15 employees don't cover the costs associated with pregnancy and birth. However, federal law requires that group plans cover maternity if a group has 15 employees or more.

medical emergency
Unexpected onset of injury or sickness which manifest itself by acute symptoms of sufficient severity, including severe pain such that a prudent layperson, who possess an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part

medically necessary
Service, drug or supply needed for the diagnosis or treatment of an injury or sickness in accordance with generally accepted standards of medical practice, if at the time the service, drug, or supply is provided it shall be considered "necessary" if it is ordered by a licensed Doctor or Physician, or if it is commonly or customarily recognized through the medical profession as appropriate for the particular injury or sickness for which it was ordered and being used

The person whose life or health is insured under an insurance policy for which he or she has paid premium.

mental health - inpatient
Inpatient mental health care is generally reserved for severe mental health problems, such a schizophrenia and severe depression. State laws vary widely on the degree to which insurance companies must cover mental illness. Most plans do provide some coverage, though there may be limitations such as the severity or nature of the illness and the duration of care.

mental health - outpatient
Outpatient mental health benefits are generally divided into two categories, severe and non-severe health care. State laws vary widely on the degree to which insurance companies must cover mental illness. Most plans do provide some coverage, though there may be limitations such



A group of doctors, hospitals and other health-care providers contracting with a health plan, usually to provide care at special rates and to handle paperwork with the health plan.

non-formulary drugs
Non-formulary drugs often require a higher copayment. Non-formulary drugs are those that have not yet been reviewed or have been denied formulary status, typically because they offer no extra benefit over the drugs already on a plan's formulary list.

non-severe mental health
Non-severe mental health problems are generally psychologically-based, such as phobias, manias and mild-to-moderate depression. In most cases, these problems can be treated without a stay at a treatment facility.

nurse practitioner (NP)
A registered nurse who has completed specific advanced nursing education (generally a master's degree) and training in the diagnosis and management of common as well as a few complex medical conditions.



office visit
Any time you visit a doctor at his or her office for medical care.

Health care services received outside the HMO, POS or PPO network.

out-of-pocket expense
Any medical care costs not covered by insurance, which must be paid by the insured.

outpatient surgery
Surgery that does not involve an overnight stay in a hospital.

over-the-counter (OTC) drugs
Are medicines that may be sold directly to a consumer without a prescription from a health care professional, as compared to prescription drugs, which may only be sold to consumers possessing a valid prescription.



Parkinson's disease (also known as Parkinson disease or PD)
A degenerative disorder of the central nervous system that often impairs the sufferer's motor skills, speech, and other functions.

A set of exclusive rights granted by a state (national government) to an inventor or their assignee for a limited period of time in exchange for a public disclosure of an invention.

Any person who receives medical attention, care, or treatment. The person is most often ill or injured and in need of treatment by a physician or other medical professional.

patient care
Health care or healthcare is the prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical, nursing, and allied health professions.

Penicillin (sometimes abbreviated PCN or pen)
A group of antibiotics derived from Penicillium fungi.

A profession charged with the safe use of medication, traditionally, pharmacists have compounded and dispensed medications on the orders of physicians. More recently, pharmacy has come to include other services related to patient care including clinical practice, medication review, and drug information. Some of these new pharmaceutical roles are now mandated by law in various legislatures. Pharmacists, therefore, are drug therapy experts, and the primary health professionals who optimize medication management to produce positive health-outcomes.

Health professionals who practice the art and science of pharmacy. In their traditional role, pharmacists typically take a request for medicines from a prescribing health care provider in the form of a medical prescription and dispense the medication to the patient and counsel them on the proper use and adverse effects of that medication. In this role, pharmacists ensure the safe and effective use of medications. Pharmacists also participate in disease state management, where they optimize and monitor drug therapy - often in collaboration with physicians and/or other health professionals. Pharmacists have many areas of expertise and are a critical source of medical knowledge in clinics, hospitals, and community pharmacies throughout the world. Pharmacists are sometimes small-business owners, owning the pharmacy in which they practice. They are also very skilled and specialized individuals with specific knowledge that makes them a vital part of any healthcare team. They act as a learned intermediary between patients and healthcare providers to ensure that proper medical therapy is chosen and implemented in the best way possible. Pharmacists are sometimes referred to as chemists (or dispensing chemists), which sometimes causes confusion with scientists in the field of chemistry. This term is a historical one, since pharmacists originally were required to complete an undergraduate degree in Pharmaceutical Chemistry (PhC) and were known as "Pharmaceutical Chemists"

pharmaceutical industry
Develops, produces, and markets drugs licensed for use as medications.[1] Pharmaceutical companies can deal in generic and/or brand medications. They are subject to a variety of laws and regulations regarding the patenting, testing and marketing of drugs.

The study of the physiological effects of drugs on the body or on microorganisms or parasites within or on the body and the mechanisms of drug action and the relationship between drug concentration and effect.

pharmacokinetics, sometimes abbreviated as PK, (from Ancient Greek pharmakon "drug" and kinetikos "to do with motion")
A branch of pharmacology dedicated to the determination of the fate of substances administered externally to a living organism.

physical therapy
Not all plans cover physical therapy -- a program of special exercises that can help an injury heal without restricting movement or limiting function.

physician - also known as medical practitioner, doctor of medicine, medical doctor, or simply doctor
practices the ancient profession of medicine, which is concerned with maintaining or restoring human health through the study, diagnosis, and treatment of disease or injury.

physician assistant (PA)
A healthcare professional licensed to practice medicine with supervision of a licensed physician.[1] A physician assistant is concerned with preventing, maintaining, and treating human illness and injury by providing a broad range of health care services that are traditionally performed by a physician.

point-of-service plan
An HMO plan that also incorporates an indemnity plan option allowing members to obtain medical care from providers outside of the HMO network at a reduced benefit and at greater out-of-pocket expense.

A written document that contains the terms of the contractual agreement between an insurance company and the owner of policy.

policy year
The period of time that the policy is to remain in force.

policy owner
The person or business that owns an insurance policy.

portable coverage
Group insurance coverage that can be continued by an insured employee who leaves the covered group.

pre-admission certification
A component of utilization review under which the utilization review organization determines whether an insured's proposed non-emergency hospital stay or some other type of care is most appropriate and what the length of an approved hospital stay may be.

pre-existing condition
According to most individual health insurance policies, an injury that occurred or a sickness that first appeared or manifested itself before the policy was issued and that was not disclosed on the application for insurance, According to most group health insurance policies, a condition for which an individual received medical care during three or six months immediately prior to the effective date of his coverage.

pre-existing conditions provision
A health insurance policy provision stating that benefits will not be paid for any illness and/or condition that existed prior to one becoming an insured under the particular health plan in question, until the insured has been covered under the policy for a specified period.

preferred provider organization (PPO)
An organization where providers are under contract to an insurance company or health plan to provide care at a discounted or negotiated rate. Typically, you can see any doctor in the PPO network without requiring special approval, and you usually do not need to choose a primary care physician. Most PPOs will also allow you to seek care outside of the PPO network; however, the benefits are usually reduced and the insured has a greater out-of-pocket expense.

A specified amount of money that the insurer receives in exchange for its promise to provide health insurance to an individual or a group.

prescription drug
A licensed medicine that is regulated by legislation to require a prescription before it can be obtained. The term is used to distinguish it from over-the-counter drugs which can be obtained without a prescription.

prescription drug coverage (Rx)
A type of specified expense coverage that provides benefits for the purchase of drugs and medicines prescribed by a physician and not available over-the-counter. Often a plan will provide a prescription drug card that allows the insured to obtain medications by simply paying a copay at a participating pharmacy.

primary care physician (PCP)
A general or family practitioner who serves as the insured's personal physician and first contact with a managed care system. The PCP will usually direct the course of your treatment and/or refer you to other doctors and/or specialists in the network.

probationary period
The length of time that a new group member must wait before becoming eligible to enroll in a group insurance plan.

Probenecid (Benuryl)
A uricosuric drug that increases uric acid excretion in the urine. It is primarily used in treating gout and hyperuricemia.



The preliminary amount of premium the insured and/or group will pay per month before underwriting factors are considered.



receptor antagonist
A type of receptor ligand or drug that does not provoke a biological response itself upon binding to a receptor, but blocks or dampens agonist-mediated responses.

renewal date
The specified date of when the health insurance coverage will renew for another period, typically one year.

risk management
the practice of appraising and controlling risk, has evolved as a discrete field of study and practice.

routine annual exam
A yearly medical "checkup," during which your doctor will perform simple medical care such as checking your height, weight, vision and blood pressure, as well as screening for problems like colon cancer, cervical cancer, prostate cancer and high cholesterol.

rx drug: formulary/non-formulary
Some plans divide all drugs into two categories: formulary or non-formulary. If you have drug coverage, your prescription (RX) co-payment may be different for formulary and non-formulary drugs.



severe mental health
As defined by the American Psychiatric Association in their Diagnostic and Statistical Manual (DSM), severe mental illness includes the following disorders: schizophrenia, schizoaffective disorder, bipolar disorder (manic-depressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa and bulimia nervosa. Such problems generally require at least occasional inpatient care.

short-term disability
This type of coverage pays a percentage of your salary if you become temporarily disabled, meaning that you are not able to work for a short period of time due to sickness or injury (excluding on-the-job injuries, which are covered by workers compensation). The per-week amount is usually 50, 60 or 66 2/3 percent of your weekly salary, and lasts for a period of time specified by the plan.

short-term medical coverage
Similar to flex-term medical coverage. Short-term medical coverage is a major medical plan designed to protect you in the event of an illness or injury during "gaps" in your traditional medical coverage -- when you are between jobs or plans, a recent graduate, on strike, etc. Short-term plans are not meant to cover routine exams and preventive care; if you are looking for a choice of plan types and the ability to renew your plan beyond one year, a traditional medical plan, while typically more expensive, may be a better fit for your health insurance needs.

Illness or disease, which is the sole cause of loss, all illnesses due to the same related sickness is considered one sickness

skilled nursing
A level of care for patients who need intensive, 24-hour nursing supervision. This can take place in the home or in skilled nursing facilities, which offer services such as rehabilitation and specialized nutrition.

small-group plan
A health insurance plan that is specifically designed for employers with a number of employees under a specified amount.

standard industrial classification (SIC)
The Standard Industrial Classification (SIC) system is a series of number codes that attempts to classify all business establishments by the types of products or services they make available. Establishments engaged in the same activity, whatever their size or type of ownership, are assigned the same SIC code. These definitions are important for standardization. Insurance companies use SIC codes to determine specific rates for various industries. uses these codes to ensure that you receive the best possible rate for your occupation.

standard risk rate
The risk category that is composed of proposed insureds who have a likelihood of loss that is not significantly greater than average.

stop-loss provision
A major medical policy provision under which the insurer will pay 100 percent of the insured's eligible medical expenses after the insured has incurred a specified amount of out-of-pocket expenses in deductible and coinsurance payments.

supplemental accident
This kind of coverage provides extra financial security for you and your family in the event of accidental death or dismemberment.



term life insurance
A type of life insurance that provides a death benefit if the insured dies during a specific period.



Insurance company employees who are responsible for identifying and classifying the degree of risk represented by a proposed insured.

The process of identifying and classifying the degree of risk represented by a proposed insured.

urgent care
Urgent care is appropriate when a medical urgency arises which necessitates immediate care, but has not reached the level of extreme emergency. Most managed care plans require you to seek urgent care at a participating urgent care facility or hospital.

usual, customary and reasonable fee
The maximum dollar amount of a covered expense that is considered eligible for reimbursement under a major medical policy.



vision care coverage
A type of specified expense coverage that provides benefits for expenses the insured incurs in obtaining eye examinations and corrective lenses.



well baby care
The goals of well baby care are 1) to immunize; 2) to provide parents with reassurance and counseling on safety, nutrition and behavioral problems; and 3) to identify and treat physical and developmental problems.



Primarily used for diagnostic radiography and crystallography.



We apologize for the inconvenience, however, at this time we have no insurance or related glossary terms beginning with the letter "Y".



We apologize for the inconvenience, however, at this time we have no insurance or related glossary terms beginning with the letter "Z".