Deductible is the amount of covered expenses you must pay out of your pocket each calendar year before the plan begins to pay benefits. Most plans have different deductibles for in-network and out-of-network providers.
Coinsurance is the percentage of covered expenses you must pay when you receive medical care. For example, in some health plans, you may pay 20 percent of the cost for most procedures and the plan covers the remaining 80 percent. The coinsurance amount you pay is after you have met your deductible for the calendar year.
Out-of-pocket maximum is the most you pay out-of-pocket in a calendar year for eligible medical expenses. Both your coinsurance and your deductible expenses count toward your out-of-pocket maximum. If you reach the out-of-pocket maximum, the plan pays 100 percent for most additional eligible expenses for the rest of the calendar year. Most plans have separate out-of-pocket maximums for in-network and out-of-network charges.
Copayment is the fixed dollar amount you must pay for care. For example, in some health plans, you may pay a small copayment of $20 to $35 for an office visit to an in-network provider. Copayments are usually collected at the time you receive services.
Network providers have agreed to charge fees that are at or below your medical plan's allowable amounts. Therefore, if you visit network doctors and hospitals, you will not have to worry about being billed for amounts above allowable limits.
Out-of-network providers have not agreed to keep their charges within your plan's allowable amount and may charge any amount for services or supplies. If you visit an out-of-network provider, you are responsible for paying any amount above your plan's allowable amount for the services or supplies you receive. In addition, you'll pay your normal copayment or coinsurance. Charges above your plan's allowable amount do not count toward your deductible or out of pocket maximum.
Making Your Health Care Decision
When deciding which plan best meets the needs of you and your family, you have several things to consider. Think about the following questions as you decide which plan is best for you.
- How much premium will be taken from your paycheck?
- What do you have to pay for a primary care office visit?
- How much do you anticipate paying out of your pocket under each medical plan after benefits are paid?
- Will you have the potential of being charged more than your medical plan's usual and customary?
- Are your doctor and your hospital in the medical plan's network?
- If not, are you willing to change to a doctor or hospital that is in the network?
- If your provider is not in the network, are you willing to accept a lower benefit to continue using the provider if he or she does not agree to join the network?
- Use Castlight, the health care shopping tool, for cost and quality information.
- Does the medical plan let you go in- and out-of-network?
- Do you need a referral to go to a specialist?
- Do you have to choose a primary care physician (PCP) to manage all your care?
- Is the network nationwide?
(This is helpful if you travel or have covered dependent children going to school out of the area.)
- How much paperwork are you willing to do?
Primary Care Physicians - Who Needs One?
Contacting or seeing a primary care physician before you see a specialist can usually help you get the right type of care without wasting time or money. If you're having a problem that you think requires a specialist, your primary care doctor can confirm if a specialist is needed and which kind of specialist with your medical history and other background.
Primary care physicians typically include family practitioners, internists, pediatricians, and OB/GYNs. Their training prepares them to focus on a patient's overall health, as opposed to the health of only a specific part of the patient. Because of this training, your primary care physician can develop a broad understanding of your whole medical history and help guide you through the complex maze of medical services.
By developing a relationship with a primary care physician, you will have a partner familiar with your background, needs, and personality should you ever have a serious illness or injury. Primary care physicians can help identify the most appropriate specialist for a particular condition, help coordinate care among multiple specialists, watch for potential harmful drug interactions, and provide appropriate follow-up care.
In-Network or Out? It's Your Responsibility to Know.
All of Purdue's medical options include provider networks, making it important for everyone to be aware of which doctors are in their medical plan's network and which are not.
If your doctor is in your network and needs to refer you, in most cases he or she should refer you to specialists or hospitals that are in your network so that you'll receive higher benefits. However, a referral from an in-network doctor is no guarantee that the specialist belongs to your plan's network. And networks change throughout the year with providers joining and dropping out. It is your responsibility to confirm whether a doctor belongs to the network serving your plan.
Castlight, the health care shopping tool, shows your in-network providers and lets you compare them by cost and quality. You can also see which health care providers are in your network by going to myCigna.com and following the "Find a Doctor or Service" tab.
Instructions for registering as a myCigna.com user are available through the "Learn How to Register" tab at the top of the login page.
Generic vs. Brand Name Drugs
You probably know by now that brand name drugs usually cost much more than their generic equivalents. In fact, brand name drugs can cost three to ten times as much as generic drugs.
The question most people have is, “Are generic drugs comparable to brand name drugs?” The answer is, “yes.” Generics are simply drugs that have previously been marketed under brand names, but the manufacturer's patent has expired. These patents typically expire after 17 years. This means that the drug has at least 17 years of clinical data behind it. The expiration of the patent allows other manufacturers to make and market the drug, without the expense of development and advertising costs.
The U.S. Food and Drug Administration (FDA) requires that each generic drug contain the same key active ingredients, strength, and dosage form as the brand name version. Generic drugs must also pass the same FDA standards for quality and clinical effectiveness. A critical factor in evaluating a drug's therapeutic value is the rate at which it's absorbed into the blood stream. A generic drug must absorb as quickly as the brand name drug and must act the same way in the body and have the same effect as the brand name version.
Need to Find a Doctor?
Everybody wants a doctor whose services are convenient, not too expensive, and of top medical quality. But how do you find one?
Select the kind of doctor you want. If you want a generalist who can be a “family doctor” for you and your family, look for someone who is certified in family practice, general practice (GP), or internal medicine (internist). Other logical choices for different family members are OB/GYNs for women and pediatricians for children, or a particular specialist for patients with major chronic illnesses. Your primary care physician can help you with finding an appropriate specialist.
Find a few to choose from. Your medical plan network can make finding a doctor easier because it provides lists of doctors in your area. The lists are usually divided by specialty. These doctors have also agreed to offer their services at negotiated rates so, if you are enrolled in their network, you know you'll get cost-effective care. You can narrow the list by location, by asking friends for recommendations, or by asking doctors or nurses you know.
To see which doctors are in your network, go to myCigna.com and follow the "Find a Doctor or Service" tab. Instructions for registering as a myCigna.com user are available through the "Learn How to Register" tab at the top of the login page.
You can also use Castlight, the health care shopping tool, to find in-network providers and compare them by quality and cost.
Call the office of the doctors you are interested in and ask the staff about the doctor's qualifications and the convenience and costs of the care. Tell the receptionist that you are trying to find a new regular doctor. Ask if the doctor is accepting new patients. If so, then ask a few questions:
- Ask qualifications questions to help you learn about the doctor's specialty, medical education, residency, years of experience, board certification, and hospital admitting privileges.
- Ask convenience questions to determine office hours, average wait time for an appointment, how coverage is arranged for evenings, weekends, and holidays, and if the doctor will discuss problems over the phone.
- Ask cost questions to ensure that your doctor is still participating in your network plan and, if you require a specific procedure, ask the cost of that procedure.
If you prefer, you can find the answers to most of these questions through Castlight, the health care shopping tool.
Talk with the doctor. Ask if you can schedule a “get acquainted” appointment and if there is a charge for it. Use the visit or phone call to ask questions, share your medical history, and get to know the doctor's personality and bedside manner. Take a list of questions with you so you'll be sure to cover all the points that are important to you.